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D - Health Care Services and Support

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1. initials Do not obliterate the order Step down doses of medication or increasing doses shall be documented on the MAR as individual orders for each step Identify the numbers of days or doses for each step by drawing a box around the days or by using arrows to point to the days for a given step As each step of the medication stage is completed the order shall be d c d and hi lited When the am dose of a medication is different from the pm dose the medication order shall be written on the MAR as two separate orders Write the date PRN medication is ordered from the pharmacy to alert other staff of order or presence of medication in the facility Any specific instructions for administering the medication shall be written directly on the MAR not on a yellow sticky Examples continue current dose until new dose arrives crush med in refrigerator NF resent med ordered re faxed Red ink may be used for this purpose Dental contingency medications or contingency medications ordered by the Podiatrist and Optometrist shall be documented on the MAR as dispensed by the prescriber Revision Dates 12 15 11 NUMBER D 2 19d Page 4 of 4 TRANSCRIPTION OF ORDERS 29 30 31 32 33 34 35 36 Multiple page MARS shall be labeled as 1 of 3 2 of 3 3 of 3 unless previously labeled by the pharmacy The inmate s housing location may be noted on the MAR in pencil When all orders have been transc
2. Effective Date 12 20 01 POLICY The University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall administer medications in a timely manner according to the orders of the prescribing practitioner and in accordance with applicable state and federal laws while caring for Connecticut Department of Correction CDOC inmate patients The UCHC Pharmacy shall provide pharmacy service to UCHC CMHC gt Principles of Medication Administration Distribution pg 3 gt Receipt of Medications by the Facility pg 4 gt Administration of Medications pg 5 gt Self Administration of Medications pg 6 gt Documentation pg 6 gt PRN Medications pg 7 gt Discontinuation of Medications pg 7 gt No Show Refused Medications pg 7 gt Inmate Transfers pg 8 gt Pharmacy Problems pg 8 DEFINITIONS Administration The act in which a single dose of a prescribed drug or biological is given to an inmate by an authorized person The complete act of administration includes removing an individual dose from a previously dispensed properly labeled container verifying it with the practitioner s order giving the individual dose given OR the transfer of prepackaged properly labeled medications to an individual for self administration according to directions provided by the prescribing practitioner Administration is limited to nurses practitioners and trained persons in accordance with C G S Sections 20 14h to 20 14
3. Compounding The act of selecting mixing combining measuring counting or otherwise preparing a drug or medication Contingency Drugs A supply of drugs approved by the CMHC Pharmacy and Therapeutics Committee readily available in pyxis or in a locked medication cabinet located in the CDOC facility health services unit for use in prescribed drug therapy when the inmate specific medication has not arrived from the pharmacy Revision Dates 6 11 02 6 18 03 10 01 04 11 23 04 06 28 05 03 30 07 04 20 07 01 31 08 05 12 08 09 22 08 07 31 09 02 28 11 06 30 11 12 15 11 07 25 12 01 28 13 NUMBER D 2 19 Page 2 of 9 MEDICATION ADMINISTRATION DISTRIBUTION Controlled Drugs Any medication that is on Schedules II V of the CT Statute and others identified by CDOC CMHC Delivery The movement of a labeled prepackage container of multiple doses of drug to the inmate when inmate self administration and possession is permitted Dispensing Those acts of processing a drug for delivery or administration to an inmate pursuant to the order of a practitioner Dispensing consists of 1 comparing directions on the label with the directions on the prescription or order to determine accuracy 2 selection of the drug from stock to fill the order 3 counting measuring compounding or preparation of the drug 4 placing the drug in the proper container affixing the label to the container and 5 the addition of any required notations
4. KOP based in part on the following factors e The inmate patient possesses the appropriate cognitive physical and visual ability to self administer medication The medication is suitable for self administration Suitability of the medication to be carried by the inmate and or stored at the bedside Desired level of security with respect to the likelihood of abuse There shall be a written order from the CMHC prescriber for all medication s that can be self administered by the inmate patient Continued approval of the self administration of medication by the inmate is dependent on the inmate s compliance with physician orders and facility procedures e KOP medications shall be documented on the MAR using the number of days 7d days 4d Documentation All DOT and KOP and nurse protocol medication administered refused or omitted medication shall be recorded on the inmate s Medication Administration Record MAR There shall be one MAR for each inmate with both on line and KOP medications all pages of the MAR shall be numbered The CMHC staff member shall record the administration of scheduled doses of medication by entering his her initials in the space provided on the inmate s MAR under the date and on the line for the specific drug dose administration All nurse protocol medications shall be written on the Physician Order Sheet HR 925 for co signing by a prescriber Upon administration or delivery of a prescribed medicat
5. above 7 An inmate who claims indigence but whose number does not appear on the list must take up the issue with the CDOC Counselor NUMBER D 2 21 Page 3 of 3 NON FORMULARY OVER THE COUNTER ITEMS REFERENCES CMHC Administrative Policy D 2 19 Medication Administration Standards for Adult Correctional Institutions 4 Edition 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 3 01 Page 1 of 2 HEALTH SERVICES CLINIC SPACE EQUIPMENT AND SUPPLIES Effective Date 04 01 01 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC in conjunction with Connecticut Department of Correction CDOC shall ensure that sufficient and suitable space equipment and supplies are available for maintaining adequate health care delivery to inmates in each CDOC facility PROCEDURE CMHC Health Services Administrators HSA in conjunction with CDOC Unit Administrators shall ensure that e Examination and
6. for longer than 24 hours when it is not possible to determine a resolution within the day of discovery Discrepancies are automatically purged from the Pyxis system after 7 days Failure to resolve a discrepancy within this 24 hours period shall be treated by the CMHC Pharmacy as an unresolved discrepancy see Unresolved Discrepancies below This may necessitate the filing of a controlled substance loss report with the DEA and could precipitate an audit Narcotic discrepancies shall be immediately corrected when identified Incident reports are to be initiated and the appropriate CMHC Nursing Supervisor and HSA shall be notified if resolution cannot be obtained Each facility shall designate an area accessible to health services location for placement of the two keys required to open the back of the Pyxis machine The keys should be secured in a locked box optimally glass Removal of the keys from the designated area shall be accompanied with an Incident Report The keys shall be counted at the beginning of each shift when a nurse is present Nursing The following procedure is recommended to allow for the prompt resolution of controlled substance discrepancies The main advantage of this method is that it lessens the amount of time invested in attempting to recreate the circumstances leading up to a discrepancy Step Detection At the end of each shift two licensed nurses shall inventory all controlled substances The report shall be read
7. All controlled substance medications shall be inventoried by two licensed nurses when received from the Pharmacy and immediately placed in the controlled substance drawer or compartment The record of receipt of controlled substances from the pharmacy shall include the full signatures of two licensed nurses The record of receipt shall be faxed back to the pharmacy Copies of records of receipt pharmacy manifest shall be kept at the facility in a readily available manner for three 3 years In the event that only one licensed nurse is on site to receive controlled substances from the pharmacy the nurse shall implement one of the following e Secure the pharmacy sealed tote with the controlled substances under double lock until the licensed nurse on the next shift arrives to count OR e Secure the pharmacy locked tote with the controlled substances under double lock until a second licensed nurse is available to count For those meds not in Pyxis each controlled substance shall have an individual proof of use sheet CMHC Form HR 905 Accountability Record to document individual patient administration doses Proof of Use sheets shall be entered onto the Proof of Use Accountability log Quantities of patient controlled substance medications stored within the mobile cart shall be limited to the minimum quantities necessary to provide for normal efficient operation and shall be promptly removed for proper disposal when no longer needed by
8. CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 18 Page 1 of 3 EMERGENCY MEDICATION BOX Effective Date 02 01 01 POLICY Connecticut Department of Correction CDOC staff in conjunction with University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that emergency medications are available and maintained at every CDOC health services unit PROCEDURE A Registered UCHC Pharmacist shall initially distribute the Emergency Medication Box A list of the contents of the emergency box is attached to this policy UCHC Pharmacy Services shall be responsible for the replacement of used emergency medications via exchange of the entire Emergency Medication Box vs individual contents of the box A CMHC facility staff member shall call the facility assigned pharmacist to make arrangements for a replacement Emergency Medication Box UCHC Pharmacy Services shall be responsible for monitoring expiration dates for emergency medications to ensure that replacement boxes arrive on time Emergency Medication Boxes shall be locked at all times The presence of a secured lock shall be documented at the beginning of each shift that a CMHC provider is present The documentation shall be entered on HR 902 Change of Shift Accountability Record for The appropriate CMHC Nursing Supervisor designee shall be responsi
9. HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 15 Page 1 of 3 INMATE PERSONAL MEDICATION Effective Date 8 20 99 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall generally discourage inmates from bringing personal medications into Connecticut Department of Correction CDOC facilities In the event that an inmate s personal medication is brought into a CDOC facility on admission a chain of custody shall be maintained to avoid diversion prevent accidental loss and assure proper disposition of such medications PROCEDURE When an inmate possessing personal medication is admitted to any CDOC facility the following procedures will be instituted 1 The Correctional Officer takes custody of any personal medication from the inmate immediately upon admission to the facility 2 The Correctional Officer shall deliver this medication to CMHC staff as soon as possible 3 CMHC staff shall assume custody of the medication and initiate CMHC Form HR 713A Inmate Personal Medication Receipt 4 CMHC staff shall inventory the medication present and record the information on Form 713A Inmate Personal Medication Receipt The following data elements are required e Inmate name amp number Prescription number Medication name and strength Quantity Date of receipt Signatures of receiving CMHC staff and CMHC witne
10. HSA The HSA shall notify the Unit Administrator and the CMHC Designated Director CMHC staff shall verify the loss by conducting a complete inventory of all remaining controlled substances with another CMHC licensed staff member The controlled substances unaccounted for shall be determined by using this inventory the most current previous inventory and receipt and disposition records Contact should be made with the Designated Director and Director of Nursing designee within one 1 hour of initial discovery The CMHC CHNS designee shall again notify the HSA of the nature and extent of the loss within one hour of the determination Form CN 6601 Incident Report page 1 shall be generated by the staff member who initially reported the loss suspected loss The HSA and or CMHC Nursing Supervisor designee shall conduct brief interviews with any staff pertinent to the loss and direct all parties to provide written statements by completing CN 6601 Incident Report Supplemental Page 3 If not on site the HSA and Designated Director and Unit Administrator designee shall be updated within one hour of the initial notification The Nursing Supervisor designee shall complete the DEA Form 106 Report of Theft or Loss of Controlled Substances on line see below within 24 hours The form is located on the CMHC Portal DEA website Revision Dates 06 28 05 06 30 10 07 25 12 NUMBER D 2 14 Page 2 of 2 CONTROLLED DRUG LOSS PROTOCOL The o
11. REFERENCES Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL CMHC Patient Safety System PSS User Manual Rev 3 2008 Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Date 6 18 03 11 23 04 05 12 08 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 10 Page 1 of 1 RECORD OF DESTRUCTION OF PARTIAL OR INDIVIDUAL DOSES CONTROLLED SUBSTANCES NON PYXIS Effective Date 3 30 99 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that a record of destruction when not available or recordable in PYXIS is maintained on the Form HR 905 Accountability Record whenever partial or individual doses of controlled substances are discarded by CMHC staff in Connecticut Department of Correction CDOC facilities PROCEDURE The record of destruction shall include the inmate name identification number medication name dosage form strength and quantity of controlled substance destroyed The documentation shall include the full signatu
12. Time Procedure a If the repair cannot be made from the WSC then the Correctional Nursing Supervisor CHNS or designee and UCHC Pharmacy should be notified This will implement a Down Time Procedure where orders may be faxed to the pharmacy until the repair can be accomplished As soon as orders start coming to the Pharmacy as faxed orders the downtime procedure calls for the Pharmacy to place the orders in the proper sequence based on scanned orders previously sent When the WSC has completed repairs and tested the system the Downtime will be over and the Correctional Nursing Supervisor or Designee and Pharmacy will be notified that orders will no longer be faxed CLINICAL ISSUES 1 Order Problems a b Orders will be reviewed by pharmacist comparing them to the inmate profile in the Siemens Pharmacy System In the event that the order cannot be processed because of information problems the order will be annotated with notations indicating the reason for the problem The order will be printed back to the facility using the PRINT BACK function The nurse at the facility should promptly review the print back order and attempt to resolve the problem NUMBER D 2 20a AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM Page 3 of 3 PYXIS CONNECT ORDER MANAGEMENT SYSTEM 2 Clinical Problems a Clinical problems dealing with items like allergies incorrect order information dose errors etc should be reviewed and
13. all other locking devices on each cart and such keys shall not be interchangeable between carts within the same facility Mobile Medication Carts when not in use shall be locked and stored within a limited access locked and enclosed medication room or closet or other substantially enclosed structure Mobile Medication Carts shall be securely locked at all times when unattended All medication and injection equipment shall be stored within the locked cart Locking devices shall be maintained in good working order The separate controlled substance drawer or compartment shall be securely locked at all times except for the actual time required to remove or replace needed items or conduct a physical inventory or pharmacy inspection The keys to the controlled substance drawer or compartment of each mobile cart shall be kept separate from the other locking devices of the cart and shall be carried personally by the nurse responsible for administering medications The CMHC Nursing Supervisor or designee shall conduct unannounced documented physical inventories of the controlled substance stock on all units at a minimum monthly The results of the physical inventories shall be documented on Form HR 718 Correctional Hospital Nursing Supervisor Designee Monthly Pharmacy Inspection and forwarded to the CMHC Health Services Administrator Revision Date 06 28 05 NUMBER D 2 04 PAGE 2 OF 2 MOBILE MEDICATION CART STORAGE CONTROLLED SUBSTANCES
14. based on a prescriber s order or nursing judgment Medication No Shows When a patient does not come to a scheduled medication call to obtain a prescribed medication Non Legend Drugs Drugs commonly referred to as over the counter drugs available for use without the written order of a practitioner These drugs are available from the commissary and health staff consistent with CMHC Nursing Protocol interventions for treatment of minor and uncomplicated illness or discomfort Revision Date5 6 11 02 6 18 03 10 01 04 11 23 04 06 28 05 03 30 07 04 20 07 01 31 08 05 12 08 09 22 08 07 31 09 02 28 11 06 30 11 12 15 11 07 25 12 01 28 13 NUMBER D 2 19 Page 3 of 9 MEDICATION ADMINISTRATION DISTRIBUTION Pharmacist A person duly licensed by the Connecticut Commission of Pharmacy to engage in the practice of pharmacy pursuant to C G S Section 20 594 Pharmacy Care The functions and activities encompassing the procurement dispensing distribution storage and control of all pharmaceuticals used within the facility the monitoring of inmate drug therapy and the provision of inmate patient drug information Parenteral Administration Administration of medication by a route other than by mouth These include subcutaneous intravenous intramuscular topical intra arterial intraperitoneal intrathecal intracardia and intrasternal routes Prescriber A physician dentist psychiatrist optometrist podiatrist
15. be included on the inmate s Visitor s List Exceptions to this procedure may be made upon the recommendation of the prescriber when the inmate is taking a medication that is needed for continued treatment and is not on the UCHC formulary or may be difficult to obtain from the UCHC pharmacy e g medication for the treatment of Hepatitis C or is extremely expensive Inmate personal medication should not be used to avoid seeking approval for a non formulary drug or to administer a medication for which non formulary approval has been denied 12 In certain cases when an inmate is admitted with a non formulary medication that a physician deems necessary for urgent inmate need such medication will be identified and administered by nursing staff See Policy D 2 16 Inmate Personal Medication Identification DISPOSITION OF PERSONAL MEDICATIONS An inmate designated friend or family member may pick up personal medications within 30 days of receipt admission The inmate must designate in writing on the Form HR 713A Inmate Personal Medication Revision Dates 6 18 03 7 21 04 06 30 08 06 30 10 NUMBER D 2 15 REFERENCES Page 3 of 3 INMATE PERSONAL MEDICATION Receipt the identity of that individual The receiving individual shall sign for receipt of the medications on the original copy of the Form HR 713A Inmate Personal Medication Receipt and the CMHC Nurse shall document the disposition on the Form HR 713 Record of
16. be inventoried by two licensed nurses when received from the Pharmacy then immediately placed in the proper drawer s and verified by the RX check The record of receipt of controlled substances from the pharmacy manifest shall be done on the same date of delivery and shall include the full signatures of two licensed nurses The record of receipt shall be faxed back to the pharmacy Copies of records of receipt pharmacy manifest shall be kept at the facility in a readily available manner for three 3 years One of the licensed nurses signing the record of receipt manifest shall be responsible for placing the controlled substances in the pyxis machine refilling and the second nurse shall serve as a witness to the refilling process In the event that only one licensed nurse is available to receive controlled substances from the pharmacy the nurse shall secure the pharmacy sealed controlled substance tote under double lock in the pharmacy room until the 2 nurse arrives to count At a minimum two off going nurses shall inventory the controlled substances each shift and make the inventory report readily accessible to the on coming nurse The on coming nurse shall review and sign the inventory report Any discrepancy shall be resolved before the on coming nurse signs the inventory report All discrepancy reports shall be forwarded to the CHNS for review All reports shall be kept for one week See D 2 20 Automated Me
17. compliance An unscheduled monthly compliance inspection shall be conducted by the CMHC Nursing Supervisor or HSA designee The monthly accountability log sheet shall be reviewed by the Nursing Supervisor designee Revision Date 11 19 03 05 07 04 12 13 10 01 20 11 02 28 11 12 15 11 NUMBER D 3 02a Page 3 of 3 SHARPS ACCOUNTABILITY REFERENCES Administrative Directive 6 6 Reporting of Incidents 2005 Connecticut Department of Correction Administrative Directive 7 1 Key and Tool Control 2005 Connecticut Department of Correction CMHC Dental Manual Standards for Health Services in Prisons P D 03 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Kathleen Maurer MD Revision Date 11 19 03 05 07 04 12 13 10 01 20 11 02 28 11 12 15 11 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 4 01 Page 1 of 2 DIAGNOSTIC SERVICES Effective Date 10 15 00 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall ensure that appropriate diagnostic services are provided to inmates in custody of the Connecticut Department of Correction CDOC PROCEDURE Di
18. for the prophylaxis diagnosis or therapy of disease or for the modification of physiological functions In developing a working definition of an ADR any undesirable or unexpected event that requires discontinuing a drug modifying the dose prolonging institutionalization or providing supportive treatment should be assessed as a possible ADR ADR s or suspected ADR s shall be managed in the facility in accordance with the following procedures e An ADR or suspected ADR shall be documented on Form HR 710 Adverse Reaction to Medication and reported as soon as possible to the attending physician and the HSA e CMHC staff shall document the ADR or suspected ADR in the inmate s HR e CMHC staff shall describe in a full incident report the ADR or suspected ADR e CMHC staff shall monitor and document the inmate s condition in accordance with instructions from the facility physician Each HSA shall collect reports of ADR s or suspected ADR s occurring in the facility and forward them to the Designated Director who shall present them at the Pharmacy and Therapeutics P amp T Committee quarterly meeting The P amp T Committee shall review all incidents and report confirmed or unexpected ADRs to the FDA on FDA Form 1639 which is completed by the physician Revision Dates NUMBER D 2 19b Page 2 of 2 ADVERSE REACTIONS REFERENCES Administrative Directive 8 3 Pharmacy Care 2007 Connecticut Department of Co
19. forwarded to the prescriber or covering physician for correction b Orders should be corrected by having the prescriber enter orders discontinuing the problem order and making new orders as required per CMHC policy C Orders should be scanned to UCHC Pharmacy NURSE MONITOR SOFTWARE 1 To enable the nurse to monitor the progress of orders entered in the Pyxis Connect System the Pyxis Medstation as well as specified computers have been equipped with this software Please see training and procedure documents for further details Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Date UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 21 Page 1 of 3 NON FORMULARY OVER THE COUNTER ITEMS Effective Date 07 06 04 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall establish guidelines for prescribing non formulary over the counter OTC items to Connecticut Department of Correction CDOC inmates PROCEDURE 1 If an inmate requests any item that is primarily of a cosmetic nature the health services staff shall advise the inmate that the items are available in
20. given in the physician order or as established by CMHC policy e Wrong Dosage Form Variance Administration of a drug by the correct route but in a different dosage form than that specified by the physician An example of this type of variance is the use of an ophthalmic ointment when a solution was ordered After consulting appropriate resources purposeful alteration e g crushing of a tablet or substitution e g substituting liquid for a tablet of an oral dosage form to facilitate administration is generally not an variance e Wrong Time Variance Administration of a dose of drug greater than 1 hour before or after the facility medline time scheduled administration time e Wrong Preparation of a Dose Incorrect preparation of the medication dose Examples are incorrect dilution or reconstitution not shaking a Suspension using an expired drug not keeping a light sensitive drug protected from light and mixing drugs that are usually chemically incompatible e Incorrect Administration Technique Situations when the drug is given via the correct route site and so forth but incorrect technique is used Examples are not using Z Track injection technique when indicated for a drug incorrect instillation of an ophthalmic ointment and incorrect use of an administration device Medication variances shall be managed in the facility in accordance with the following procedures e A medication variance shall be reported immediatel
21. in Connecticut Department of Correction CDOC facilities be immediately removed and placed in an immobile safe or otherwise locked permanently secured box while awaiting destruction PROCEDURE The medication nurse shall reconcile the medication quantity with CMHC Form HR 905 Accountability Record or the UCHC Pharmacy Proof of Use Sheet before personally handing it to the CMHC Nursing Supervisor or designee If the CMHC Nursing Supervisor is not available to receive the medication the medication shall remain on active count until it can be personally handed to the CMHC Nursing Supervisor Only the CMHC Nursing Supervisor shall have a key to the locked container for drugs awaiting destruction The CMHC Nursing Supervisor shall prepare the drug destruction sheet Inventory as drugs are added to the separately locked box or container The number amount of the controlled substance medication shall be reconciled with the proof of use sheet before being placed in the approved receptacle for destruction Any discrepancy shall be reported immediately to the appropriate CMHC Health Services Administrator REFERENCES Standards for Adult Correctional Institutions 4 Edition 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC D
22. nurse practitioner advanced practice nurse physician assistant or other person authorized to prescribe drugs in the course of professional service in the State of Connecticut PRN Drug A drug which a prescriber has ordered to be administered only when needed under certain circumstances Refusal When a patient asserts that he she will not take a prescribed medication Facility Specific Health Services Unit Procedure Addendum A written procedure for the administration distrioution of medications within the facility The facility procedure addendum shall include the following e Times and locations of medication administration distribution e Provisions for furnishing medications to inmate patients on administrative or disciplinary segregation to those inmates participating in work programs and to others who cannot attend the regularly scheduled medication distribution e Other medication procedures unique to the setting facility PROCEDURE Principles of Medication Administration Distribution It is essential that medications be accurately administered in order that the desired therapeutic effect is achieved Nursing personnel involved in the administration distribution of medications shall consistently employ the five rights of medication administration Right patient Right medication Right dosage Right route Right time e All medication shall be labeled in accordance with established UCHC professional principles
23. of Use POU document A licensed nurse or pharmacist shall log POU documents onto the Active Proof of Use Log Sheet immediately upon arrival The prescription number shall serve as the POU serial number In cases where a given prescription number appears on more than one card the receiving nurse shall designate cards as one of three two of three three of three etc by marking the prescription label with the appropriate letter The current POU Log shall be maintained behind the change of shift signature form in the front of the Controlled Drug POU binder The POU Log shall be updated whenever a receipt or other disposition of a controlled drug issue occurs by the licensed nurse affecting the receipt disposition see the POU Log form Possible legitimate dispositions may include inmate transfer or secured for destruction due to damage discharge or expiration The CMHC Nursing Supervisor designee shall issue a new POU log sheet on a monthly basis transferring the information from the currently in use sheets from the previous month s document to the new one This updated POU log sheet shall be available for the first change of shift audit of each calendar month The previous month s log will be maintained with the completed change of shift signature sheet During change of shift inventories the on coming and off going nurses will verify the presence of all Proof of use sheets on the POU Log prior to checking the counts Discrepancies sh
24. shall be discontinued or rewritten for patients discharged from an infirmary If continued orders for these medications shall be rewritten for a maximum of 30 days at a time All orders for class Il Ill IV and V drugs shall be administered on line Renewal order dates may be rewritten on the MAR no more than 3 times A line shall be drawn through the old date and the new date for renewal written in ink Revision Date NUMBER D 2 19d Page 2 of 2 TRANSCRIPTION OF ORDERS REFERENCES Administrative Directive 8 3 Pharmacy Care 2007 Connecticut Department of Correction CMHC Pharmacy Manual Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Correctional Health Care Chicago IL Connecticut General Statutes Chapter 420b 420c CMHC Patient Safety System PSS User Manual Rev 3 2008 Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title Director of Health Services Daniel Bannish PsyD Revision Dates UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 20 Page 1 of 8 AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM Pyxis Effective D
25. sign the Proof of Use sheet verifying the contents quantity of the inmate specific Class Il V medication and make a photocopy of the Proof of Use sheet for the facility records The transfer shall be documented on the Proof of Use Accountability Log form The sending facility shall document the quantity of and transfer of Class Il III IV and V medications on the Form HR 005 Transfer Summary Electronic Transfer Summary HR 005 E and call the receiving facility to alert them of the incoming medications To ensure timely processing and administration of medications the inmate must be transferred to the receiving facility in the Patient Safety System after the Electronic Transfer Summary HR 005 E has been printed The receiving transfer facility shall repeat the verification process with two nurses and sign that the quantity of medications arrived safely at the receiving facility The receiving nurse shall document the receipt of controlled substances on the Transfer Summary Form and shall enter the same onto the Proof of Use Accountability log Any discrepancy shall be reported immediately to the appropriate CMHC Health Services Administrator HSA and Form CN 6601 Incident Report page 1 completed Form HR 714 Medication Administration Variance Report shall be completed as appropriate at the direction of the HSA Revision Date 6 18 03 11 23 04 05 12 08 NUMBER D 2 09 Page 2 of 2 INMATE FACILITY TRANSFER CONTROLLED SUBSTANCES
26. the Pharmacy and placed in an electronic queue for processing based on the date and time received TECHNICAL PROPLEMS 1 Error Messages a TONER LOW the scanner uses toner to print returned messages when the cartridge is low replacement is done the same way other laser devices are handled Follow the instructions on the cartridge compartment Toner Cartridges are available through usual supply Revision Date NUMBER D 2 20a AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM Page 2 of 3 Revision Date PYXIS CONNECT ORDER MANAGEMENT SYSTEM channels Contact the Correctional Health Nursing Supervisor CHNS or their designee PAPER JAM Documents may jam in the scan tray or output tray Remove the paper as necessary CHECK CABLE The check cable error message indicates that the scanner and computer are not linked properly Check cables to machines as wall as the wall outlet and data port Following the check reboot the system by turning off the scanner and its computer Turn on the scanner then the computer The system should re establish a connection and Insert Original will appear in the display If the scan station does not function properly call the Cardinal Pyxis Worldwide Support Center using the toll free number found on the scanner The technical support center will attempt to diagnose the problem and repair it remotely A field service technician may have to be dispatched to the facility 2 Down
27. the testing product control solution is questionable i e unusual color of a urine dipstick test strip e A questionable inmate patient result is obtained e The integrity of the instrument has been compromised i e instrument dropped left on heater etc e Anon instrument container is found opened If quality control passes re cap container and continue to use If quality control fails document results and discard the container When quality control fails troubleshooting shall be performed according to Quality Control Decision Tree in the Decentralized Lab testing Procedure Manual Quality control checks shall be performed by R N LPNs and qualified laboratory technicians All containers of decentralized lab testing materials shall be dated when opened Revision Date 01 12 05 02 28 11 NUMBER D 4 02 Page 2 of 2 QUALITY CONTROL OF FACILITY LAB EQUIPMENT Containers of testing products and quality control solutions shall be discarded when they have reached their expiration date All quality control checks shall be documented and signed by the individual performing the checks on the Decentralized Lab Quality Control Log All health services staff performing patient testing shall know how to perform and document Quality Control tests The CMHC Nursing Supervisor or designee shall review and sign the Quality Control Logs at least once a month The HIV Program Health Services Administrator shall review and sign the ORAQUIC
28. to the written prescription Dispensing does not include the acts of distributing or administration of that drug to the inmate The function of dispensing is limited to pharmacists and authorized prescribers Distributing The movement of a drug in the originally labeled manufacturer s container or in a labeled prepackaged container from the pharmacy to a nursing service area Dose The amount of drug to be administered at one time DOT Direct observation therapy as ordered by a prescriber inmate is observed as single dose medication is administered Drug An article recognized in the United States Pharmacopoeia Official Homeopathic Pharmacopoeia of the United States or Official National Formulary or any supplement to any of them intended for use in the diagnosis cure mitigation treatment or prevention of disease in humans Drugs other than food are intended to affect the structure or any function of the body of humans Formulary A list of drugs approved for use This list contains legend non legend and controlled drugs KOP Keep on person as ordered by a prescriber medication is delivered to the inmate to be taken independently by the inmate Legend Drugs Any article substance preparation or device that bears the legend Federal law prohibits dispensing without a prescription Legend drugs are available for use on the written order of a practitioner Medication Hold When a medication is temporarily held
29. C Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Dates 05 14 02 06 18 03 05 30 05 06 28 05 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 02 Page 1 of 1 MOUTH CHECKS FOLLOWING MEDICATION ADMINISTRATION Effective Date 02 4 99 POLICY Mouth checks shall be performed on inmates by health services staff or CDOC custody staff following the administration of all controlled substances psychoactive medications or medications identified by the nursing staff or physician Liquid medications or crushed medications shall be utilized in Restrictive Housing or similar security environments whenever possible as ordered by the prescriber PROCEDURE Following the administration of medication the nurse or custody officer shall instruct the patient to Open wide lift tongue swing tongue left swing tongue right If the inmate is found to be hoarding a medication cheeking the inmate shall be given a direct order to swallow the medication If the inmate refuses to comply with the order the correctional officer if not present shall be called The inmate shall not leave the medication area The nursing staff shall complete a Medical Incident Report CN 6601 Inmates found to be non compliant with ingesting prescribed medications shall be counsele
30. C nurse as a reminder of transaction activity e Return of Controlled Substances The Return Med feature should be used only when the user is physically returning an unused intact medication to the Pyxis unit The user will return the item back into stock with a witness present for controlled substances A second licensed nurse shall witness this activity To accomplish this use the inventory icon on the control panel Both nurses shall sign the inventory receipt and forward it to the CHNS designee e Wasting Medications Controlled Substances If all or part of a medication originally taken from the station has been wasted it will be documented at the station by using the Waste Med option Two nurses are required to document waste of a controlled substance Medication wastes are defined as all or part of a medication that is not in its original package and not administered to an inmate patient This includes accidental breakage of an ampule tubex etc The waste procedure is to be entered immediately before or after the time the medication is wasted e Entering Patient Information Revision Date 06 28 05 12 28 06 02 28 11 06 30 11 NUMBER D 2 20 Page 8 of 8 AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM In instances where the Medstation Rx information is not current the CMHC nurse should manually enter the inmate patient using the Add Patient prompt during the remove med function refer to Medstation Rx Oper
31. Health Care Chicago IL Connecticut General Statutes Chapter 420b 420c CMHC Patient Safety System PSS User Manual Rev 3 2008 Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director of Health Services Kathleen Maurer MD Revision Dates 12 15 11 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 19e Page 1 of 2 REORDERING MEDICATIONS Effective Date 02 28 11 POLICY The University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall administer medications in a timely manner according to the orders of the prescribing practitioner and in accordance with applicable state and federal laws while caring for Connecticut Department of Correction CDOC inmate patients The UCHC Pharmacy shall provide pharmacy service to UCHC CMHC PROCEDURE All orders for Class II drugs prescribed for patients shall be rewritten for a maximum of 30 days at a time All orders for Class III IV and V drugs prescribed for patients shall be rewritten for a maximum of 6 months at a time All orders for non controlled drugs prescribed for patients shall be rewritten at the discretion of the prescriber for a maximum of one calendar year at a time Orders for injectable Class II drugs
32. K Advance Rapid HIV 1 2 Antibody Test Quality Assurance Manual during the facility site audit REFERENCES Standards for Health Services in Prisons P D 04 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Date 01 12 05 02 28 11 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 5 01 Page 1 of 1 HOSPITALIZED AND SPECIALIZED AMBULATORY CARE Effective Date 04 01 01 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall provide for hospital and specialized ambulatory care to Connecticut Department of Correction CDOC inmate patients utilizing UCHC John Dempsey Hospital and University Medical Group When an emergency or unusual circumstance precludes the use of UCHC facilities other Connecticut hospitals may be utilized to provide care to CDOC inmate patients in accordance with Connecticut State Statute 18 52a PROCEDURE A current signed Memorandum of Agreement between UCHC and CDOC shall be maintained in the office of the CMHC Executive Director REFERENCES Connecticut State Statute 18 52a Hospitalization of prisoners
33. PA APRN name strength quantity of controlled substance administered and full signature title of the CMHC staff member administering the medication Completed proof of use sheets shall be kept in a 3 ring binder in chronological order by drug by inmate specific by contingency and readily available for three 3 years The administration of controlled substances shall be documented on Form HR 716 Medication Administration Record MAR PRN as needed medication shall be documented as to the time and date of administration The effects of the medication shall be documented for infirmary patients REFERENCES Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman PhD MD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 12 Page 1 of 1 OUTDATED OR DISCONTINUED CONTROLLED SUBSTANCES Effective Date 3 30 99 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that outdated controlled substances
34. Page 2 of 2 ORDERING MEDICATIONS See PYXIS procedures for receipt loading of medications CMHC Policy 2 20 Automated Medication And Supply Distribution System REFERENCES Standards for Adult Correctional Institutions 4 4382 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Date 05 30 05 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 04 Page 1 of 2 MOBILE MEDICATION CART STORAGE CONTROLLED SUBSTANCES Effective Date 03 30 99 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that Mobile Medication Cart storage of controlled substances in Connecticut Department of Correction CDOC facilities meets all federal and state regulations for storage of controlled substances PROCEDURES The Mobile Medication Cart shall have a separate lockable non removable drawer or compartment for storage of all controlled substances The key that locks the controlled substance drawer or compartment shall be different from the keys to
35. Pyxis Pharmacy System terminal located in the CMHC Pharmacy The CMHC Nursing Supervisor or designee shall grant a CMHC staff member a temporary password to cover the time period before a permanent password is assigned All permanent Pyxis users are given an initial password of NEW This functions only as an initial log on and forces the user to enter a new password before being allowed access to the medication stock The new password should be at least 3 digits letters or numbers to enhance security and shall not be obvious such as the user s name Willful abuse or inappropriate use of the employee s electronic signature is expressly prohibited and may result in termination of employment Temporary Passwords Revision Date 06 28 05 12 28 06 02 28 11 06 30 11 NUMBER D 2 20 Page 3 of 8 AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM To allow a float and or per diem nurse access to the Medstation Rx unit the CMHC Nursing Supervisor or designee may assign a new nurse temporary access for twelve 12 hours At the end of twelve hours this temporary I D automatically expires The temporary D can only be used at the medstation in the CDOC facility where it was created The temporary password will have the same access privileges as the standard nursing password When creating temporary codes the temporary user s full first and last name shall be entered Password Access Levels Individual CMHC staff members may have differen
36. RENCES Connecticut Department of Consumer Protection Regulations for Controlled Drug Security 21 262 1 21 262 3a Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICIES AND PROCEDURES FOR USE IN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 14 POLICY PROCEDURE Page 1 of 2 CONTROLLED DRUG LOSS PROTOCOL Effective Date 3 30 99 University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that any loss or suspected loss of a controlled substance in a Connecticut Department of Correction CDOC facility is reported immediately CMHC staff shall notify the facility CMHC Nursing Supervisor or designee immediately upon discovery of any irresolvable discrepancy with regard to controlled substance accountability The CMHC Nursing Supervisor or designee shall immediately notify the CMHC Health Services Administrator HSA and the pharmacy manager designee of the incident and hold all CMHC staff on duty until released by the
37. Receipt and Disposition of Personal Medication 1 Inmates discharging within 30 days of admission shall have all personal medications returned to them along with other personal property at the point of discharge Custody staff shall be alerted to the existence of personal medications during the final review of the inmate file by noting the presence of the carbonless copy of the Form HR 713A Inmate Personal Medication Receipt The CMHC Nurse shall document the disposition on the Form HR 713 Record of Receipt and Disposition of Personal Medication In situations where medications non controlled are held unclaimed for 30 days they may be destroyed at the facility by health services staff by placing in the medical waste disposal system a safety proof puncture resistant water proof container See Pharmacy Policy 17 00 Drug Disposal Controlled drugs must be destroyed by 2 licensed pharmacists Pharmacists will document disposition on the Form HR 713 Record of Receipt and Disposition of Personal Medication and in the case of controlled drugs on the HR 712 Controlled Substance Destruction Log All available copies of the Form HR 713A Inmate Personal Medication Receipt pertinent to the destroyed products shall be disposed of All records associated with this process shall be secured and available for inspection for not less than three years except as noted in f 3 above Those records not in active use shall be maintained in a fi
38. TH AGAINST THE CURRENT MAR REFERENCES Administrative Directive 8 3 Pharmacy Care 2007 Connecticut Department of Correction CMHC Pharmacy Manual Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Correctional Health Care Chicago IL Connecticut General Statutes Chapter 420b 420c CMHC Patient Safety System PSS User Manual Rev 3 2008 Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Johnny Wu MD Title CDOC Director of Health Services Kathleen Maurer MD Revision Dates 05 28 13 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 19b Page 1 of 2 ADVERSE REACTIONS Effective Date 02 28 11 POLICY The University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall administer medications in a timely manner according to the orders of the prescribing practitioner and in accordance with applicable state and federal laws while caring for Connecticut Department of Correction CDOC inmate patients The UCHC Pharmacy shall provide pharmacy service to UCHC CMHC PROCEDURE An Adverse Drug Reaction ADR is defined by the World Health Organization as any response which is noxious unintended and occurs at doses normally used in man
39. UMBER D 2 20a Page 1 of 3 AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM PYXIS CONNECT ORDER MANAGEMENT SYSTEM Effective Date 09 11 07 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC Pharmacy and Nursing Services shall use the Pyxis Connect Order Management System to process prescriber orders for medication and routine supplies in Connecticut Department of Correction CDOC facilities DEFINITION The Pyxis Connect Order Management System is a network based system for transmitting medication information from treatment facilities to the UCHC Pharmacy for review and processing It consists of a scanning device an Order processing station and Nurse Monitor software PROCEDURE ACCESS TO SCANNER 1 Nurse Access a The nurse checks the Scan Station to confirm that the device is ready for use The user display will indicate ready with a direction Insert Original b Place the document in the tray print side down with the top of the printing inserted first c Pressing the Scan button will load the document for processing The completed document will come out of the lower tray d The input tray will accept multiple documents 10 20 is recommended depending on paper thickness scanning them continuously until the tray is empty e If there is a problem with the scan an error message will appear in the user display f The scanned orders will be transmitted to
40. UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 01 Page 1 of 2 CONTROLLED SUBSTANCE COUNT Non Pyxis Facilities Effective Date 02 04 99 POLICY The controlled substance count shall be completed at the beginning and end of each nursing shift by the nurses involved in medication administration PROCEDURE No controlled substances shall be permitted at medical level 2 facilities Medical level 3 facilities without pyxis The count shall be completed by the on coming nurse who will be administering the medications and the off going nurse who has administered the medications or held the controlled substance keys Both nurses shall sign CMHC Form HR 902 Change of Shift Inventory Record for Controlled Substances Accountability sheets shall be maintained at the facility for a period of three 3 years UCHC pharmacist shall review the above at the time of the monthly pharmacy inspections Facility CMHC Nursing Supervisor s or their designee shall be responsible for checking the accountability record at least three 3 times a week and if possible daily The Nursing Supervisor designee shall sign and date the HR 902 Change of Shift Inventory Record for Controlled Substances form UCHC pharmacist shall verify the above at the time of the monthly pharmacy inspection An incorrect controlled substance coun
41. a Learning Management System and attest to completion of the annual Pyxis training Following the attestation the UCHC Pharmacy Clinical Coordinator will authorize the nurse as a certified Pyxis user and notify the HSA and CHNS via e mail Nurses will not be authorized as certified Pyxis users until authorized by the pharmacy Revision Date 06 28 05 12 28 06 02 28 11 06 30 11 NUMBER D 2 20 Page 2 of 8 AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM Following authorization as a certified Pyxis user newly hired and appropriate CMHC staff shall receive additional on site training on Pyxis by trained CMHC staff members at the facility The CHNS shall identify a facility preceptor for the training The preceptor shall use a CMHC approved check list and or any other teaching tools to facilitate this training All training shall include return demonstrations to ensure proficiency All documentation of such training shall be forwarded to the CMHC Director of Education and Training to ensure credit hours for the training is documented in the educational database In addition as per policy C 1 01a UCHC CMHC Employee Files and Personnel Records a copy of the completed orientation checklist shall be forward to UCHC human resources and a copy maintained in the employee facility file Password Issuance and Security The CMHC employee s sign on identification and password will serve as the employee s electronic signature in the Pyxis system A
42. agnostic x ray services and laboratory testing shall be available at selected CDOC facilities consistent with the level of health care provided at those facilities A CMHC Radiology and or UCHC Laboratory Manual shall be located on the CMHC Portal and on site at those CDOC facilities where these diagnostic services are provided Each CMHC Health Services Administrator HSA shall maintain a list of the diagnostic x ray services available at each CDOC facility in their complex This list shall be included in the functional unit copy of the Radiology Procedure Manual and as an attachment to this policy In those CDOC facilities where Laboratory diagnostic services are available a complete catalog of laboratory tests specimen requirements instructions as to proper collection and processing and procedures for the calibration of testing devices shall be available in the UCHC Laboratory Manual located on the UCHC website In those instances when diagnostic testing and or services are ordered for an inmate are not available at the facility where the inmate is housed the inmate shall be referred to another CDOC facility where the service is available or the UCHC laboratory and or radiology department where the testing shall be completed See Policy P 1 05 Laboratory Ordering Results Reporting Revision Date 08 09 05 NUMBER D 4 01 Page 2 of 2 DIAGNOSTIC SERVICES REFERENCES UCHC Laboratory Manual CMHC Radiology Manual Standards for H
43. al Association Standards for Health Services in Prisons P D 03 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Date 08 09 05 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 3 02 Page 1 of 2 SHARPS NEEDLE AND SYRINGE CONTROL Effective Date 04 01 01 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that sharps needles and syringes in all Connecticut Department of Correction CDOC facilities are accounted for at all times PROCEDURE In order to maintain security control and inventory each CDOC facility s CMHC Nursing Supervisor and Dentist Podiatrist shall be responsible for maintaining appropriate inventory and records on all sharps needles and syringes in their areas of responsibility and clinical practice Inventories shall be maintained at a minimum on a daily basis Discrepancies in inventories of items subject to abuse shall be reported immediately both verbally and in writing to the appropriate CMHC Health Services Administrator HSA utilizing Form CN 6601 Incident Report The CMHC HSA s
44. all be reported to the CMHC Nursing Supervisor immediately Revised Date 05 14 02 6 18 03 NUMBER D 2 08 Page 2 of 2 CONTROLLED DRUG RECEIPT INVENTORY PROTOCOL REFERENCES Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director of Health Services Daniel Bannish PsyD Revised Date 05 14 02 6 18 03 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 09 Page 1 of 2 INMATE FACILITY TRANSFER CONTROLLED SUBSTANCES Effective Date 03 30 99 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that inmate specific prescribed Class II Ill IV and V controlled substances be transferred with an inmate at the time of transfer to another Department of Correction facility PROCEDURE The transfer nurse shall verify that the controlled substance inventory is in agreement with the contents of the controlled substance container at the time of transfer This verification shall be witnessed by a second nurse Both sending nurses shall
45. all inform the inmate that future items should be obtained through the commissary Examples are constipation remedies and tinea creams e OTC Pharmacy Items The prescriber shall complete Form HR 708 Non Formulary Exception Drug Request for the OTC item i e multivitamins for pregnancy or advanced HIV inmates and include the following information o The OTC item o Medical indication for its use The request shall be sent to the CMHC Medical Director for review Results of the review shall be sent to the requesting facility and the pharmacy If despite the health services staff recommendation an inmate requests non formulary OTC items or makes a recurring request for free items from the Nursing Protocol stock health services staff shall reinforce with the inmate to access the item from the commissary CMHC Central Office shall generate a list of inmate numbers for all inmates who are indigent This list is available on the CMHC portal If an inmate is indigent as defined and verified by CDOC Inmate Accounts and health services staff shall assess that a medical need for the item is present as outlined in numbers 2 and 3 a non formulary exception request shall be initiated the item shall be administered from OTC Stock or administered according to the nursing protocols A copy of the appropriate page of the inmate indigent list shall be accepted as documentation for a non formulary OTC request described
46. alth Services Daniel Bannish PsyD Revision Dates UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 19d Page 1 of 5 TRANSCRIPTION OF ORDERS Effective Date 02 28 11 POLICY The University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall administer medications in a timely manner according to the orders of the prescribing practitioner and in accordance with applicable state and federal laws while caring for Connecticut Department of Correction CDOC inmate patients The UCHC Pharmacy shall provide pharmacy service to UCHC CMHC PROCEDURE 1 A practitioner initiates a valid medication order by phone or in writing using CMHC Form HR 925 Physician s Order Sheet A valid medication order shall include the inmate name number time date medication name strength route dose dosage form duration or number of units frequency directions for use including DOT or KOP and prescriber name e Contingency Medication For medication started from contingency the prescriber shall note on the order start immediately or start from contingency The prescriber shall use an approved CMHC name stamp or print his her name under the signature for clarity A licensed nurse shall document a telephone order in the inmate Health Record HR on CMHC Form HR 925 Ph
47. and items not physically stored inside of the machine as remote stock These items and removals such as wastes returns etc shall be treated the same as items stored in Pyxis and must be keyed in The configuration of each facility Pyxis unit is initially determined by the CMHC Pharmacy based on the historic medication usage of that facility so as to best utilize the available spacing Any requests for changes to the established inventory items or par levels should be directed in writing to the CMHC Pharmacy by the respective CMHC Nursing Supervisor Revision Date 06 28 05 12 28 06 02 28 11 06 30 11 NUMBER D 2 20 Page 4 of 8 AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM Inventory Maintenance CMHC facility nursing staff shall be responsible for the refill and loading of medications supplies in the Medstation Rx units CMHC pharmacy personnel shall inspect each Pyxis machine and review the activity reports at the time of the pharmacy inspection These reports shall include All Stations Event Discrepancy Resolution Reports and Returns and Waste Fill lists are generated via the Pharmacy Pyxis Console on a regular schedule Lists are filled and delivered to CDOC facilities on an as needed basis Record Keeping The pharmacy console will store information for thirty days after which the information is archived to disk A hard copy of the information is preserved through a set of reports that is gen
48. ate 12 20 01 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC Pharmacy and Nursing Services shall use the Pyxis Automated Medication and Supply Distribution system in Connecticut Department of Correction CDOC facilities for the storage record keeping and distribution of the following e Controlled substances e Non controlled substances e Routine supplies The Pyxis Medstation Rx is a microprocessor controlled secure storage and record keeping device The station is durably built to provide secure and reliable storage for medications supplies Devices shall conform to the following specifications electronic access doors and a removable rear panel emergency access which requires two non identical keys Controlled substances will be stored in carousel drawers or mini drawers PROCEDURE In accordance with established policies and procedures for controlled substances all record keeping requirements for dispensing practices shall conform to the regulations implemented by the Federal Controlled Substances Act of 1970 and or the Connecticut Comprehensive Laws Concerning Drugs whichever is stricter for each situation Training and Inservice The CHNS at sites that utilize Pyxis machines for medication administration shall ensure that all nurses that administer medication complete the tutorial on the Pyxis machine yearly Following completion of the tutorial the nurse will access the Sab
49. ate this should be noted on the MAR along with the use of contingency meds utilized if appropriate or medications reordered from the pharmacy to duplicate the original supply Pharmacy Issues Revision Date5 6 11 02 6 18 03 10 01 04 11 23 04 06 28 05 03 30 07 04 20 07 01 31 08 05 12 08 09 22 08 07 31 09 02 28 11 06 30 11 12 15 11 07 25 12 01 28 13 NUMBER D 2 19 Page 9 of 9 MEDICATION ADMINISTRATION DISTRIBUTION Problems that arise in CDOC facilities related to the UCHC Pharmacy for example wrong drug on label wrong quantity wrong inmate patient wrong directions wrong prescriber drug ordered but not sent shall be documented on the HR 711 Pharmacy Problem Resolution Form and faxed to the UCHC Director of Pharmacy Services and CMHC QI Administrator e Aggregate data shall be reviewed at facility QI meetings and at Central QI meetings e Recommendations for education and or training or other corrective action shall be made as appropriate See related CMHC policies in Section D 2 Medication Services and the following policies Policy 2 19 a Verifying the MAR for the Upcoming Month Against the Current MAR Policy 2 19 b Adverse Reactions Policy 2 19 c Medication Variance Policy 2 19 d Transcription of Orders Policy 2 19 e Re ordering Medications eee o o REFERENCES Administrative Directive 8 3 Pharmacy Care 2007 Connecticut Department of Correction CMHC Pharmacy Manual Standards for Health S
50. ators Manual Troubleshooting CMHC facility staff shall resolve operational problems such as jammed drawers using the Station Reference Flipbook for instruction For other problems the following steps should be followed Consult the station reference flipbook troubleshooting section If the problem is not addressed contact the Pyxis 24 hour emergency hotline 1 800 727 6102 Any hardware or software problems with the facility unit should be also be addressed or followed up with the CMHC Pharmacy in an attempt to prevent future occurrences Emergency Backup Procedure In the event of a system or power failure which cannot be corrected in a timely fashion it may become necessary to manually open the station for medication access Two keys which open the rear of the Pyxis unit are available from the CMHC Nursing Supervisor or CMHC HSA The CMHC Pharmacy will be notified immediately in the event of a station failure The CMHC Nursing Supervisor CMHC HSA and on site CMHC staff will then determine whether the unit must be opened Facility staff cannot record any controlled substances removed from the station during this down time Documentation shall be performed on a manual controlled substance sign out sheet proof of use These sheets will be sent to the CMHC Pharmacy after the system is back on line See related CMHC Policies D 2 19 Medication Administration Distribution D 2 04 Mobile Medication Storage Controlled Substa
51. ble for ensuring verification of the Emergency Medication Box lock at the change of shift count and reviewing the appropriate documentation monthly Emergency Medication Boxes shall be stored in each CDOC facility health services medication pharmacy room under double lock The Emergency Medication Box breakaway lock shall be considered the first lock and the locked door to the medication pharmacy room shall be considered the second lock At no time will a facility be without an emergency medication box Revised 05 14 02 06 18 03 09 17 03 06 28 05 NUMBER D 2 18 Page 2 of 3 EMERGENCY MEDICATION BOX CDOC Incident Report CN 6601 1 page 1 shall be completed each time the Emergency Medication Box is opened and or the contents used The completed report shall be forwarded to the UCHC Pharmacy and appropriate CMHC Health Services Administrator Once the Emergency Medication Box is opened it shall be re locked with the yellow lock provided in the box while waiting for exchange REFERENCES Connecticut General Statutes Doe vs Meachum Consent Judgment 1990 Connecticut Department of Correction Standards for Adult Correctional Institutions 4 Edition 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medi
52. ble for use when it is unsafe to carry a used syringe from the injection site to the wall mounted container The staff member utilizing the mobile disposal container shall be responsible for the container at all times When not in use the mobile container shall be locked in the Medication Pharmacy room All sharps disposal containers shall be emptied when full in accordance with OSHA guidelines Health services staff shall ensure that containers are checked and changed on a regular schedule Filled sharps disposal containers shall only be disposed of in the Bio Hazardous box located in the Medication Pharmacy Room or Bio Hazardous locked room The door to the Medication Pharmacy Room or Bio Hazardous Room shall be closed and locked at all times Inmates shall not have access to sharps disposal containers Inmate workers shall be directly supervised when cleaning the Medication Pharmacy Room Approximately 2 4 weeks prior to release inmates may self administer insulin under the direct supervision of a licensed CMHC staff member The CMHC staff member shall be responsible for ensuring the proper use of and disposal of the needle s and syringe s Only one inmate at a time may self administer insulin under this supervision Syringes and needles in facility Dental Units and under the control of Laboratory Technicians shall be subject to the same accountability and disposal procedures included above Each CMHC HSA shall develop procedures for
53. by the 8 day business days of the new month e The nurse shall verify inmate name and number and compare each order on the current MAR with the corresponding order on the MAR for the upcoming month prior to implementing the new MAR e Discontinued medications shall be hi lighted out in yellow magic marker on the new MAR the pharmacy may not have received the order for discontinuation prior to the printing of the new MAR e Current medications orders not present on the new MAR generated by the pharmacy shall be written on the new MAR pharmacy may not have received the order prior to printing of the new MAR e Stop dates for all orders shall be reviewed e This is a good time to note inmate missing medications during the month and generate a referral to the prescriber e For bulk KOP meds bottles tubes inhalers note the last administration date in the column just prior to the first day of the new month This will alert nurses regarding when the next administration may occur e Carry over hepatitis vaccine administration orders and date from month to month until the series has been completed e When there is a discrepancy between the two MARs the nurse shall review the original medication order in the health record e The verified MAR for the upcoming month shall be initialed signed and dated by the nurse completing the review Revision Dates 05 28 13 NUMBER D 2 19a Page 2 of 2 VERIFYING THE MAR FOR THE UPCOMING MON
54. cal Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revised 05 14 02 06 18 03 09 17 03 06 28 05 NUMBER D 2 18 Page 3 of 3 EMERGENCY MEDICATION BOX EMERGENCY BOX CONTENTS revised 9 01 03 DRUGS Aspirin 81 mg chewable x 4 tabs 325mg equivalent Epinephrine Ampules 1 1000 1ml Dipenhydramine Vials 50 mg 1ml Haloperidol Vials 5mg 1ml Hydrocortisone Vials 100mg InstaGlucose Diazepam Syringe 10mg 2 ml Naloxone Ampules 4mg ml Dextrose 50 Syringe 50 ml Glucagon Injection Kit img Albuterol MDI 17 GM Inhaler Nitroglycerin SL Tablets 4 mg bottle all bottle SSSBSHPSHHSF A 3 See ws es NS INTRAVENOUS SOLUTIONS 5 Dextrose in Water 500ml Bag 1 9 NaCl 500m Bag 1 9 NaCl 50 ml Bag 1 IV ADMINISTRATION SUPPLIES IV solution Set 10 drops ml 2C5439s IV Start Pak IV Site Prep Kit BD 386122 Venous Catheters 16 Gauge Venous Catheters 18 Gauge Venous Catheters 20 Gauge Venous Catheters 22 Gauge Syringe with Needle 3ml IV Site Dressing Veniguard 705 4431 Saline Lock Flush C 2000 Carpuject Syringe Holder Needles 18 gauge 1 5 inch Sooo aan ow a FRNA NNNNB ND SO SS SS SS ae Sr a a Revised 05 14 02 06 18 03 09 17 03 06 28 05 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 19 Page 1 of 9 MEDICATION ADMINISTRATION DISTRIBUTION
55. ceived from the Pharmacy and immediately placed in the controlled substance drawer or compartment The record of receipt manifest of controlled substances from the pharmacy shall include the full signatures of two licensed nurses The record of receipt shall be faxed back to the pharmacy Copies of records of receipt pharmacy manifest shall be kept at the facility in a readily available manner for three 3 years One of the licensed nurses signing the record of receipt shall be responsible for placing the controlled substances in the appropriate locked box or drawer and putting the proof of use sheets in the three ring binder In the event that only one licensed nurse is on site to receive controlled substances from the pharmacy the nurse shall e Secure the pharmacy sealed tote with the controlled substances under double lock until a second licensed nurse is available to count Records of receipt manifest shall be faxed to UCHC Pharmacy and a copy kept at the facility in a readily available manner for three 3 years When only one licensed nurse is schedule to work the nurse shall inventory count the control substances at the beginning and end of the shift and sign the Change of Shift Accountability Form noting one nurse assigned Revision Dates 06 18 03 06 28 05 06 30 08 NUMBER D 2 07 Page 2 of 2 RECORD OF RECEIPT FOR CONTROLLED SUBSTANCES Pyxis Facilities All controlled substance medications shall
56. commissary and cosmetic items will not be prescribed Cosmetic items include e Special soaps e Lotions e Dandruff shampoos e Acne creams 2 Nursing Staff If an inmate presents for treatment evaluation of a medical physiologic condition that health services nursing staff deems appropriate for treatment by non formulary OTC drugs and which is covered by a CMHC Nursing Protocol the health services nursing staff may administer the appropriate treatment as documented in the CMHC Nursing Protocols OTC medications administered according to CMHC approved Nursing Protocols shall be documented on Form HR 925 Physician Order Sheet and transcribed on the Medication Administration Record MAR Health services staff shall inform the inmate that if there is a recurring need for the item it should be obtained through the commissary Examples are constipation remedies and tinea creams 3 Prescriber Staff If an inmate presents for treatment evaluation of a medical physiologic condition that health services prescriber staff deem medically necessary for treatment by non formulary OTC drugs the following shall be implemented NUMBER D 2 21 Page 2 of 3 NON FORMULARY OVER THE COUNTER ITEMS 4 D e OTC Contingency Items Item can be ordered utilizing Form HR 925 Physician Order Sheet and transcribed on the Medication Administration Record MAR with a notation that the item has been filled from stock Health services staff sh
57. d by a licensed nurse regarding the purpose of the medication s the advantages of taking the medication s the potential effects of not taking the medication s and the facility procedure for medication administration The counseling session shall be documented in the inmate s Health Record Repeated incidents of non compliance with swallowing medications shall be reported to the prescriber and the CMHC Health Services Administrator REFERENCES Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revised Date 05 14 02 6 18 03 09 17 03 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 03 Page 1 of 2 ORDERING MEDICATIONS Effective Date 3 30 99 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall ensure that all CMHC prescribers ordering medication including non formulary medications and Class Il Controlled Substances are written on CMHC Form HR 925 Physician Order Sheet by the appropriate CMHC practitioner PROCEDURE Medication orders shall include the date and time of the order inmate patien
58. dication and Supply Delivery System for Resolution of Discrepancies REFERENCES Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Dates 06 18 03 06 28 05 06 30 08 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 08 Page 1 of 2 CONTROLLED DRUG RECEIPT INVENTORY PROTOCOL Effective Date 03 30 99 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that controlled drug stocks in Connecticut Department of Correction CDOC facilities are kept secure and maintained at the minimum level required to provide for patient care PROCEDURE Receipt of controlled drugs shall be recorded in a manner that will facilitate accountability For non automated systems Policy D 2 20 Automated Medication and Supply Distribution System controlled drugs received from pharmacy service providers or by transfer from other correctional facilities shall be accompanied by an appropriate Proof
59. e CMHC Head Nurse shall conduct unannounced physical inventories of the controlled substance Pyxis stock at all CDOC facilities at least twice a month The results of this physical inventory shall be documented and forwarded to the respective CMHC Health Service Administrator HSA The pharmacist shall review these reports at the time of the monthly pharmacy inspections Revision Date 06 28 05 12 28 06 02 28 11 06 30 11 NUMBER D 2 20 Page 5 of 8 AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM Resolution of Discrepancies One of the most important activities in the Pyxis Automated Medication and Supply Distribution system related to proper documentation is the expedient and appropriate resolution of discrepancies in narcotic counts A discrepancy is generated when a CMHC staff user corrects a beginning count of a medication This active discrepancy triggers the Resolve Discrepancy option in the Procedure menu Discrepancy resolution requires a witness except for those individuals granted independent discrepancy resolution clearance through their password and should include opening the back of the Pyxis machine The responsibility of discrepancy resolution rests with each nursing unit All CMHC Nursing Supervisors or designee shall be responsible for reviewing discrepancy reports within 24 hours and forwarding a summary report to the HSA All discrepancies shall be resolved as they are discovered Discrepancies shall only remain active
60. e Medications shall be packaged in the manufacturer s original container or UCHC pharmacy prescription container Revision Date5 6 11 02 6 18 03 10 01 04 11 23 04 06 28 05 03 30 07 04 20 07 01 31 08 05 12 08 09 22 08 07 31 09 02 28 11 06 30 11 12 15 11 07 25 12 01 28 13 NUMBER D 2 19 Page 4 of 9 MEDICATION ADMINISTRATION DISTRIBUTION Verify prescriber order by checking the medication administration record MAR against the bottle individual medication packet or other container Verify the full name and CDOC identification number of the inmate patient receiving the medication Inmate patients shall show their ID card Staff shall NOT pre pour medication Pre pouring is defined as preparing medications for DOT administration at a time other than directly prior to the time of facility schedule for DOT medication administration Nurses will not handle individual medication tablets pills patches with bare hands Staff may pour multi doses into a cup at the time of administration A staff member shall not give medication poured prepared by someone else A staff member shall not return unused individual doses of medication to containers All medications removed from the original pharmacy packaging shall be destroyed by disposing of the medication in a biohazard sharps container Two nurses are required to document waste of a controlled substance All topical patches for controlled substances sha
61. e administration to the inmate is not a medication variance PROCEDURE Types of Medication Variances e Omission Variances The failure of staff to administer an ordered dose of medication e Unauthorized Drug Variance The administration of a medication dose to an inmate that is not authorized for the inmate This category includes but is not limited to a dose given to the wrong inmate duplicated doses or a dose given outside of a stated set of clinical variables e g medication order not to administer the drug if the resident s blood pressure falls below a predetermined level and expired medication e Wrong Dose Variance Any medication dose administered that is in different dosage than ordered by the clinician substitution of ointment vs solution liquid vs tablet oral form for parental purposeful alteration crushing dissolving In the case of ointments topical solutions Revision Dates NUMBER D 2 19c Page 2 of 3 MEDICATION VARIANCES and sprays an variance occurs only if the medication order expressed the doses quantitatively e g one inch of ointment or two one second sprays e Wrong Route Variance Administration of a drug by a route other than the route ordered by the physician Also included are doses given via the correct route but at the wrong side e g left eye instead of right eye or the wrong site e Wrong Rate Variance Administration of a drug at the wrong rate the correct rate being that
62. e issues of controlled drugs from the active count on Form HR 715 Active Drug Proof of Use Log designating them as for destruction in the disposition column e The facility CMHC Nursing Supervisor or designee shall secure these medications and their Proof of Use sheet in a locked safe or cabinet within the locked medication room The key to this cabinet or combination to this safe shall only be in the possession of the facility CMHC Nursing Supervisor or designee when prolonged absence is anticipated As each new item is added to this cabinet the facility CMHC Nursing Supervisor adds the item to Form HR 712A Controlled Drug Destruction Log Once these medications are logged into the pending destruction cabinet safe they are no longer subject to change of shift inventories NUMBER D 2 13 Page 2 of 2 CONTROLLED DRUG DESTRUCTION DISPOSAL e The UCHC CMHC pharmacist shall secure those medications pending destruction from the facility CMHC Nursing Supervisor during his her inspection and effect destruction in the presence of a second Connecticut licensed pharmacist All controlled medications will be destroyed in a manner that renders them non recoverable in accordance with CT DCP Regs 21 262 1 amp 21 262 3a Destruction shall be documented on HR 712A Controlled Drug Destruction Log which shall be maintained with the facility s other controlled drug records in the health services unit for a minimum of three years REFE
63. ealth Services in Prisons P D 04 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Date 08 09 05 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 4 02 Page 1 of 2 QUALITY CONTROL OF FACILITY LAB EQUIPMENT Effective Date 04 01 01 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall perform decentralized lab quality control activities on instruments used to deliver health care to Connecticut Department of Correction CDOC inmates Facility lab equipment is defined as but not limited to dipstick urinalysis pulse oximeters urine pregnancy equipment hemacult testing equipment diabetic sugar monitoring testing devices Clearview Complete Rapid HIV 1 2 Antibody Test etc PROCEDURE Decentralized lab quality control activities i e glucometer shall be performed at a minimum according to the manufacturer s recommendations Instrument quality control checks shall be performed on each day of patient use Quality control for equipment tests shall be performed and documented for the following reasons e The integrity of
64. ed all am or pm doses doses of DOT or one week for KOP medications the med nurse shall refer the inmate to nurse sick call Revision Date5 6 11 02 6 18 03 10 01 04 11 23 04 06 28 05 03 30 07 04 20 07 01 31 08 05 12 08 09 22 08 07 31 09 02 28 11 06 30 11 12 15 11 07 25 12 01 28 13 NUMBER D 2 19 Page 8 of 9 MEDICATION ADMINISTRATION DISTRIBUTION nurse clinician nurse designee for MH meds for discussion educating the inmate about the medication to determine if the inmate will resume taking the medication If the inmate does not agree to resume the medication a Signed Refusal Form HR 301 shall be obtained and the prescribing clinician shall be notified and the referral documented on the MAR The patient encounter and referral shall be documented in the inmate HR If an inmate refuses or misses two doses of TB 2 doses medications the nurse shall discuss educate the inmate about the medication to determine if the inmate will resume taking the medication If the inmate does not agree to resume the medication the prescribing clinician shall be notified and the referral documented on the MAR a signed Form HR 301 Refusal of Health Services shall be obtained The patient encounter and referral shall be documented in the inmate HR Every attempt shall be made to call the inmate after a single dose of missed refused medication If an inmate refuses or misses one dose of insulin 1 dose the nurse shall call the inmate
65. erated for all facilities This set of reports consists of an All Stations Event Discrepancy and Returns and Waste The reports are set up to provide a complete record of all daily activities These reports constitute a hard copy of all transactions and serve as a permanent record of controlled substance use replacing the Controlled Substances Administration Record Proof of Use Record POU POU records will be stored for 3 years Quality Assurance Improvement CMHC Pharmacy staff may conduct unannounced focused inspections to assure that refill procedures are being completed properly The refill pick up and delivery report shall be compared to the actual refill report to insure that all appropriate medications are being added to the units Periodic reports on usage wastes and refilling will be generated and compared with the Medication Administration Record MAR to verify charting and removal accuracy as part of the monthly pharmacy inspection All discrepancy and resolution reports shall be forwarded to the CHNS designee for review within 24 hours and then to the HSA CHNS designee shall review discrepancy reports for resolution and appropriateness of resolution Reports shall be maintained for one week The pharmacist shall review these reports at the time of the monthly pharmacy inspection Consistent with CMHC Policy D 2 04 Mobile Medication Cart Storage Controlled Substances the CMHC Nursing Supervisor or appropriat
66. ervices in Prisons P D 02 2008 National Commission on Correctional Health Care Correctional Health Care Chicago IL Connecticut General Statutes Chapter 420b 420c CMHC Patient Safety System PSS User Manual Rev 3 2008 Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Johnny Wu MD Title CDOC Director of Health Services Kathleen Maurer MD Revision Date5 6 11 02 6 18 03 10 01 04 11 23 04 06 28 05 03 30 07 04 20 07 01 31 08 05 12 08 09 22 08 07 31 09 02 28 11 06 30 11 12 15 11 07 25 12 01 28 13 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 19a Page 1 of 2 VERIFYING THE MAR FOR THE UPCOMING MONTH AGAINST THE CURRENT MAR Effective Date 02 28 11 POLICY The University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall administer medications in a timely manner according to the orders of the prescribing practitioner and in accordance with applicable state and federal laws while caring for Connecticut Department of Correction CDOC inmate patients The UCHC Pharmacy shall provide pharmacy service to UCHC CMHC PROCEDURE e Anew MAR shall be initiated the first day of each month for every patient on medications All MARS shall be filed in the inmate patient health record
67. for medical care Standards for Health Services in Prisons P D 05 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Date 07 23 10
68. hall verbally report the discrepancy to the CMHC Designated Director and appropriate CDOC custody personnel and monitoring panel Written records of inventories for these health service items shall be maintained at the CDOC facility health services unit for three years NUMBER D 3 02 Page 2 of 2 SHARPS NEEDLE AND SYRINGE CONTROL REFERENCES Administrative Directive 6 6 Reporting of Incidents 2005 Connecticut Department of Correction Administrative Directive 7 1 Key and Tool Control 2005 Connecticut Department of Correction CMHC Dental Manual Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 03 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 3 02a Page 1 of 3 SHARPS ACCOUNTABILITY Effective Date 04 01 01 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure the safety and accountability of all sharps including needles and syringes at all Connecticut Department of C
69. he Active Proof of Use Log Sheet Form HR 715 unless the medication is inmate specific e Contingency medications are designated for each facility and listed in the CMHC Pharmacy Formulary Controlled substance contingency medication shall be accounted for on the Certification of Disposition for Controlled Substance Inmate patient specific medications may not be borrowed but contingency stock shall be used and the Proof of Use Sheet maintained for non pyxis facilities and for remote stock at pyxis facilities gt When antibiotics are ordered to start from Contingency nursing will administer the first three days from the facility contingency supply The pharmacy will dispense the remainder of the prescription gt All medications including contingency shall be stored in designated secured areas in each facility No personal belongings backpacks purse totes etc shall be kept in areas designated for medication storage Regularly scheduled daily medications ordered qd bid tid or qid or hs shall be labeled by the pharmacy as 0800 1200 1600 and 2000 hours Scheduled medications shall be administered within 1 hour before or after the facility scheduled med line time gt Changes Adjustments in medication administration schedules may be made to accommodate court runs and outside facility trips transfers e In any situation where the nurse is unfamiliar with the medication administration route dosage or calculations and i
70. iate CMHC CHNS designee Administrator HSA shall assign this responsibility on a rotating basis Revision Date 11 19 03 05 07 04 12 13 10 01 20 11 02 28 11 12 15 11 NUMBER D 3 02a Page 2 of 3 SHARPS ACCOUNTABILITY Cases of sharps shall be counted upon arrival and contents of individual boxes counted resealed with quantity of sharps date and initials The inactive stock supply of syringes needles shall remain behind locked doors within the Medication Pharmacy Room or behind a double lock in the Dental unit or other suitable locked room Only OSHA approved sharps disposal containers shall be utilized for the purpose of sharps disposal The sharps disposal containers shall be mounted to a wall and under lock A limited number of keys shall be assigned for the wall mounted containers The appropriate CMHC HSA shall approve all key assignments All approved sharps disposal containers shall be numbered for accountability Form HR 905 Accountability Record shall be utilized to identify how many containers are available for use in use and disposed of Empty sharps disposal containers not in use shall be counted weekly and kept under lock in the Medication Pharmacy Room or other suitable locked room Filled sharps containers shall be placed in a Bio Hazard box located in the Medication Pharmacy Room or Bio Hazardous locked room until Bio Hazardous pick up time A single small numbered mobile sharps disposal container shall be availa
71. identification of said medication prior to any administration A pharmacist may be consulted to establish the identity of the medication in question e Practitioners or CMHC providers requiring assistance in drug product identification may contact the UCHC Switchboard at 860 679 2000 ask to have the pharmacist paged and or access MicroMedex through the CMHC Portal or Life Time Clinical record LCR e Once properly identified the medication may be administered to the inmate Inmates shall be provided an opportunity to pick up such property in the event of their release within 30 days or have it released to a designated individual who must be on the inmate s Visitor s list documented on HR Form 713 Record of Receipt and Disposition of Personal Medication The UCHC Pharmacy shall destroy inmate personal medication that is not released after 30 days See related CMHC policy D 2 13 Controlled Drug Destruction Disposal REFERENCES Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Dates 6 18 03 7 21 04 UNIVERSITY OF CONNECTICUT HEALTH
72. ily accessible to the on coming nurse The on coming nurse shall review the inventory record and if no discrepancy exists also sign it All discrepancies shall be resolved before the off gong nurses leave the building At the beginning of each shift the CMHC Charge Nurse or designee shall check for active controlled substance discrepancies in the Pyxis unit See above This can be accomplished by Revision Date 06 28 05 12 28 06 02 28 11 06 30 11 NUMBER D 2 20 Page 6 of 8 AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM checking the Pyxis screen If a small box with a capsule and an X through it is present then a discrepancy exists Proceed to step Il If no discrepancies exist this option will be absent Step Il Reaching A Resolution Once a discrepancy is discovered it is critical that it be resolved as accurately as possible An activity report for the specific medication in question can be run on the console for the past 24 hours through the Reports option on the main menu This may help locate problems in transactions prior to the discovery of the discrepancy Step Ill Entering A Resolution Once a resolution for the discrepancy has been determined it must be entered into the Pyxis unit at the Document Discrepancy option It is critical that the resolution information be as clear and accurate as possible The Other option from the resolution menu should be selected and an explanation keyed
73. in The Wrong Quantity Previously Entered and Counted Incorrectly options should only be used when a discrepancy is created when one does not actually exist For example Nurse A miscounts 20 Percocet when the machine states a beginning count of 21 and generates a discrepancy by saying that there are only 20 Percocet in the drawer When the next user enters the drawer and counts correctly they would find that the count is now under by 1 tablet due to the prior mistake A second discrepancy is then created This is resolved by indicating Counted Incorrectly for the first error and Wrong Quantity Previously Entered for the second These resolution options should not be used in any other circumstance Irresolvable Discrepancies Controlled Substances For any discrepancies that cannot be resolved the following procedure shall be followed 1 The staff nurse shall immediately notify the Charge Nurse or CHNS of the unresolved discrepancy The Charge Nurse or CHNS shall immediately notify the HSA and UCHC pharmacy manager designee and Unit Administrator designee of any unresolved discrepancy of a controlled substance The HSA shall notify the CMHC Designated Director 2 Proceed with the resolve discrepancy procedure outlined in the Pyxis manual Unit reference 3 Select Unresolvable Report filed from the list of explanations 4 The CMHC Nursing Supervisor designee and HSA shall be notified and CN6601 1 Incide
74. ion all pertinent information shall be recorded on the MAR which is used as a permanent record of medication administered distributed to the inmate patient gt The inmate name and number shall be entered in the appropriate space along with the current month and year gt For each medication order the following information shall be entered in the appropriate block Date of order start stop date indicate if medication is discontinued Name of drug dose or strength dosage form Route of administration Time interval or frequency of administration Duration of order and or automatic stop order Prescriber Initials of the nurse who transcribed the order Revision Date5 6 11 02 6 18 03 10 01 04 11 23 04 06 28 05 03 30 07 04 20 07 01 31 08 05 12 08 09 22 08 07 31 09 02 28 11 06 30 11 12 15 11 07 25 12 01 28 13 NUMBER D 2 19 Page 7 of 9 MEDICATION ADMINISTRATION DISTRIBUTION The nurse shall initial the appropriate block of each dose as each on line dose is subsequently administered and if appropriate name of dispensing prescriber When distributing multiple doses of medication KOP the nurse shall initial and write the number of doses distributed under the date All licensed personnel initiating the MAR form shall legibly sign or stamp their full signature professional title RN LPN and initials in the designated area The MAR shall be used to record all medications including one time medicati
75. irector of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 13 Page 1 of 2 CONTROLLED DRUG DESTRUCTION DISPOSAL Effective Date 04 01 00 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall ensure that undesired excess unauthorized obsolete or deteriorated controlled substances that exist in Connecticut Department of Correction CDOC facilities are disposed of in accordance with Regulations set forth by the State of Connecticut PROCEDURE The Connecticut State Department of Consumer Protection Drug Control Division has extended to UCHC CMHC pharmacists practicing or consulting in CDOC facilities the same authority as pharmacists in hospitals with regard to their ability to effect controlled drug destruction When any stock or supply of controlled drug is deemed undesired excess unauthorized obsolete or deteriorated the following procedures shall be adhered to e The CMHC staff member having responsibility for controlled drugs per the shift count in each CDOC facility shall identify pertinent controlled drug stocks and sign them over to the facility CMHC Nursing Supervisor or designee Only the CMHC Nursing Supervisor or designee shall sign for removal of thes
76. l unit shall be stored with Class II controlled substances in compliance with security measures as required or separately from other drugs and or substances in a separate secure locked non portable immobile substantially constructed cabinet or container PROCEDURE Controlled substance storage locations shall be securely locked except for the actual time required to remove or replace needed items Locks shall be kept in good working order with keys removed Keys to the locks shall not be left in a location accessible to unauthorized personnel All keys for controlled substance cabinets or containers shall be kept on two 2 separate holders and carried by the CMHC Nursing Supervisor or the person s assigned to medication administration REFERENCES Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 06 Page 1 of 1 BORROWING OF CONTROLLED SUBSTANCES Effective Date 03 30 99 POLICY Universi
77. le or binder in the Correctional Hospital Nurse Supervisor s CHNS office Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Dates 6 18 03 7 21 04 06 30 08 06 30 10 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 16 Page 1 of 2 INMATE PERSONAL MEDICATION IDENTIFICATION Effective Date 04 01 01 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall ensure that whenever an inmate is admitted to a Connecticut Department of Correction CDOC facility with personal medication that is not available from authorized providers in a reasonable timeframe and a physician deems it necessary for urgent inmate need such medication shall be positively identified prior to administration PROCEDURE Upon recommendation of the prescriber with a specific prescriber medication order when the inmate is taking medication e that is not on the UCHC Formulary or e may be difficult to obtain from
78. ll be disposed of in the biohazard sharps container when removed from the patient inmate s skin Staff shall return individual unused packaged medication to the pharmacy in the original container The nurse assigned to administer medication to the inmate patient shall be aware of the inmate patient s complete medication regimen and intended results of each medication administered as well as allergic reactions or other possible side effects Receipt of Medications by the Facility Upon receipt of all medications to the health services the medication shall be reconciled with individual inmate MARs Medications ordered and not received shall be communicated to the pharmacy The nurse verifying the KOP medication against the MAR shall be the same nurse who delivers the KOP medication to the inmate Administration of Medications Medications may be administered by a registered nurse RN licensed practical nurse LPN a graduate or student nurse under the supervision of an RN physician APRN or PA LPN s may not administer intravenous medication Revision Date5 6 11 02 6 18 03 10 01 04 11 23 04 06 28 05 03 30 07 04 20 07 01 31 08 05 12 08 09 22 08 07 31 09 02 28 11 06 30 11 12 15 11 07 25 12 01 28 13 NUMBER D 2 19 Page 5 of 9 MEDICATION ADMINISTRATION DISTRIBUTION For non Pyxis facilities each administered dose of a controlled substance shall be documented on the MAR and separately recorded on t
79. n individual s combination of a User ID and Password or User ID and Biometric finger scan comprise a unique electronic signature Under no circumstances is this combination to be shared with others Sharing of passwords or other willful abuse of a Pyxis password may result in disciplinary action up to and including suspension or discharge from State service User ID The User ID is comprised of an abbreviation of the CDOC facility name plus the CMHC staff member s initials In the case of two staff members having the same initials at a CDOC facility the second ID issued would be followed by the numeral one 1 Passwords The CMHC Nursing Supervisor shall approve permanent access codes Permanent access codes are granted to CMHC staff members that are scheduled to work more than one shift These codes shall be entered by and maintained in the CMHC Pharmacy Each user shall complete the Pyxis Password Authorization Form Appendix A indicating that he she understands his her responsibilities for maintaining the security of the system Each CMHC staff member s electronic signature shall be maintained and archived by the CMHC Pharmacy and will be available for inspection by the Drug Enforcement Agency DEA and the Connecticut State Division of Drug Control All additions deletions or changes to permanent access codes must be sent by the CMHC Nursing Supervisor to the CMHC Pharmacy as confidential information Privileges can only be changed at the
80. nces D 2 07 Record of Receipt For Controlled Substances REFERENCES Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Kathleen Maurer MD Revision Date 06 28 05 12 28 06 02 28 11 06 30 11 Policy D 2 20 Appendix A University of Connecticut Health Center Correctional Managed Care Pyxis System Access CONFIDENTIAL PLEASE SEND TO PHARMACY PYXIS MANAGER WHEN COMPLETED SECTION I To be completed by employee PLEASE PRINT Employee Name Job Title Unit I understand that my USER ID and PASSWORD constitute my unique electronic signature in the Pyxis system Willful abuse or inappropriate use of my User ID or Password i e sharing of my ID or Password or using another employee s ID or Password is expressly prohibited and may result in termination This USER ID will be used to track all of my transactions in the Pyxis system each of which are stamped with the time date My electronic signature will be maintained and archived by the Pharmacy and will be available for inspection by the Drug Enforcement Agency DEA and the state division of Drug Control as is presently done with handwritten signatures on controlled substances records Password Privilege
81. nd 2000 is HS The HS hour may be circled in red and the afternoon hour may be circled in green Facility specific times shall not be written on the individual medication administration records MARs Each facility shall develop facility specific unit addendum For non formulary medication enter NF the date the request form was faxed to URC the date of approval denial and the length of the approval if less that the order directly on the individual MAR This will alert others of the need to submit another NF request if appropriate If there is no response for approval denial within 3 business days the nurse shall follow up The nurse shall document if the medication is to be administered on line or given KOP lf a prescriber orders the medication to be administered on line the nurse shall not arbitrarily change the order to KOP for convenience When medications are changed from on line to KOP the MAR should reflect the last date of on line medication and the first day of KOP delivery by documenting the number days of KOP pills administered There should not be a gap between the two dates Document on the MAR if the medication is to be started from contingency and if so document C on the MAR All medications administered from contingency shall be noted as such on the MAR including bulk medications To discontinue a medication hi lite out in yellow magic marker the entire medication row and write d c date and nurses
82. nline version of Form DEA 106 has 8 sections There is a description of each section and the information you will need to successfully fill out this online form Please note that for all pages where you are required to supply information there is a section labeled Help Within 72 hours of the discovery of the theft or loss eSubmit DEA Form 106 DEA Loss Report on line located on the CMHC Portal DEA Website https www deadiversion usdoj gov webforms dtlLogin jsp ePrint four copies of the report and send one copy of the completed DEA Loss Report to Connecticut Department of Consumer Protection Division of Drug Control State Office Building 165 Capitol Avenue Hartford CT 06106 eFax copies of the DEA Loss Report along with all personnel statements and incident report to the CMHC Pharmacy Manager and Director of Nursing designee eKeep one copy of all documentation with the facility controlled drug records for not less than 3 years REFERENCES Federal Controlled Substances Act of 1970 Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Johnny Wu MD Title CDOC Director Health Services Kathleen Maurer MD Revision Dates 06 28 05 06 30 10 07 25 12 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED
83. nt Report page 1 shall be completed 5 The HSA must notify the CMHC Director of Pharmacy in writing indicating that the incident was researched but no explanation could be found 6 The Director of Pharmacy designee files a Loss of Controlled Substance form and forwards it to the Connecticut State Drug Control Division and DEA if applicable Follow Policy D 2 14 Controlled Drug Loss Protocol Revision Date 06 28 05 12 28 06 02 28 11 06 30 11 NUMBER D 2 20 Page 7 of 8 AUTOMATED MEDICATION AND SUPPLY DISTRIBUTION SYSTEM Medication Administration Medication Removal The procedure for removal of medication is the standard method described in the Pyxis Manual and Medstation Unit reference Flipbook with the following clarifications e Controlled Substances An inmate patient s name must be selected for all transactions Should an inmate patient s name not appear in the Pyxis list please refer to Entering Patient Information section below A CMHC prescriber name must be selected in order to remove a controlled substance The CMHC nurse must verify the count on all controlled substances prior to the removal of the narcotic This is to be done without exception In case of a discrepancy a discrepancy report must be initiated and resolution sought Upon completion of each transaction a transaction slip may or may not be generated at the station These slips are for unit reference only and may be discarded or utilized by the CMH
84. on and or PRN medications PRN Medications Medication given on an as needed PRN basis shall be recorded as administered by the CMHC staff member on the inmate s MAR unless the PRN medication is provided in the manner for self administration The following additional information shall be documented on the inmate s MAR on the PRN medication flow record Date and time of the administration of the medication Medication dose route of administration and if applicable the injection or application site The inmate s subjective symptoms or complaint in patient The effects of the medication given shall be documented whenever possible At a minimum medication effects shall be documented for all inmates in the infirmary The CMHC staff member s signature or initials Discontinuation of Medication When a medication is discontinued it shall be highlighted out write D C next to the last dose of the medication date and initial No Shows Refusal of Medication If an inmate patient fails to report to the designated place at the appropriate time to receive his her medication or an inmate patient actively refuses his her medication this fact shall be recorded on the MAR by initialing and circling the initials in the block and placing N S no show or R refused on the front of the MAR If an inmate refuses or misses three 3 consecutive doses of any on line prescribed medication or exhibits a pattern of refusal miss
85. on name strength route dose dosage form duration or number of units frequency directions for use including DOT or KOP time date inmate name number and prescriber last name and discipline no prescriber initials first initial for prescriber with same last name and the original date of the order 9 The nurse shall check or initial each order transcribed from the Physician s Order Sheet HR 925 to ensure that no order has been missed 10 For all orders that apply to the Patient Safety System PSS once the order has been entered in Physician Order Entry the nurse must sign in using the user sensitive ID and password and nurse note electronically sign the order entered by the Physician Prescriber 11 If an order is illegible or confusing at the time of transcription the nurse shall clarify it immediately and prior to forwarding the order to the pharmacy 12 The prescriber shall be responsible for completing the Non Formulary Drug Request form The Non Formulary Drug Request Form and the Physician Order Sheet HR 925 shall be e mailed or faxed to the medical director designee and or the chief of psychiatric services designee for action The adjudicated Non Formulary Request Form and the Physician Order Sheet shall be scanned or faxed directly to the pharmacy from CMHC Central Office and then back to the facility The facility prescriber shall review all adjudicated forms before filing in the inmate s health record The d
86. orrection CDOC facilities PROCEDURE Employee Health Care Licensed CMHC medical mental health staff shall account for syringe needle use by completing Form HR 905 Accountability Record Sharps syringes and or needles used shall be identified with a specific employee s name and employee number A new Form HR 905 Accountability Record For __ may be initiated each time additional syringes needles are added to the active supply Inmate Health Care Licensed CMHC medical mental health staff shall account for syringe needle use by completing Form HR 905 Accountability Record Sharps syringes and or needles used shall be identified with a specific inmate s number and name A new Form HR 905 Accountability Record For __ may be initiated each time additional syringes needles are added to the active supply Accountability Form 902 Change of Shift Inventory Record for Controlled Syringes or Instrument Hazardous Device shall be completed for each shift with off going and on coming staff or when responsibility for sharps transfers from one person to another staff member leaves unexpectedly changes in assignment etc For facilities that do not have 24 hour staffing a licensed nurse shall conduct the count for all staffed shifts The inactive stock supply of syringes needles butterflies blades shall be counted weekly examples of sharps include butterflies suture staple removal kit suture sets and blades The appropr
87. re of the CMHC licensed staff member destroying the controlled substance the mode of destruction ie sharps container and the full signature title of a second CMHC staff member witnessing the destruction REFERENCES Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Johnny Wu MD Title CDOC Director Health Services Kathleen Maurer MD Revision Date 01 28 13 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 11 Page 1 of 1 RECORD OF DISPOSITION OF CONTROLLED SUBSTANCES Effective Date 03 30 99 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that a record of disposition of inmate controlled substance medication be separately maintained in Connecticut Department of Correction CDOC facility patient care units and that the disposition be recorded on the Active Proof of Use Log Sheet PROCEDURE Form HR 715 Active Proof of Use Log Sheet shall include the date and time of administration full name of the inmate inmate number name of the physician
88. ribed the nurse shall draw a line across the entire page directly beneath the last order transcribed sign his her name and title and enter the date and time Do not leave any blank lines space between the last order and the signature line When discharge medication s are ordered from the pharmacy the nurse shall write d c meds ord with the date on the top of the MAR When the medication arrives in the facility the nurse shall documented here with the date and given with date when the inmate picks up the medications A stamp for this purpose has been approved All penmanship shall be legible The MAR is a legal record All nurse s initials shall be identified by a signature or name stamp on each MAR When the order has been written either documented by the nurse or written by the clinician the Physician s Order Sheet Form HR 925 shall be scanned pyxis connect to the UCHC pharmacy in a timely manner All existing medications orders shall be reviewed and rewritten if to be continued at the time of admission to the inpatient infirmary Both mental health and medical staff dental if applicable shall be involved in deciding what meds shall be discontinued and or continued REFERENCES Administrative Directive 8 3 Pharmacy Care 2007 Connecticut Department of Correction CMHC Pharmacy Manual Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Correctional
89. rrection CMHC Pharmacy Manual Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Correctional Health Care Chicago IL Connecticut General Statutes Chapter 420b 420c CMHC Patient Safety System PSS User Manual Rev 3 2008 Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title Director of Health Services Daniel Bannish PsyD Revision Dates UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 19c Page 1 of 3 MEDICATION VARIANCES Effective Date 02 28 11 POLICY The University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall administer medications in a timely manner according to the orders of the prescribing practitioner and in accordance with applicable state and federal laws while caring for Connecticut Department of Correction CDOC inmate patients The UCHC Pharmacy shall provide pharmacy service to UCHC CMHC DEFINITION A medication variance is broadly defined as a dose of medication that deviates from the physician s order as written in the inmate s HR or from CMHC policies and procedures Except for variances of omission the dose must actually reach the inmate a wrong dose that is detected and corrected befor
90. s Standard Nurse Standard Temp Password Issuance Other Employee Signature Date Nursing Mgmt Signature Date SECTION II To be completed by Pharmacy Pyxis Manager User ID Date Entered Initialed Appendix B Pyxis Inventory Maintenance Sheet Nursing Unit Date In order to minimize the possibility of discrepancies going unrecognized for lengthy periods of time a complete inventory of all controlled substances should be performed on the Pyxis machine per CMHC Policy D 2 08 Controlled Drug Receipt Inventory Protocol An inventory is performed by selecting Inventory from the Procedure Menu Each drawer should then be selected one at a time Inventory Completed By Please Print Signature Witness to Inventory Please Print Signature CMHC Nursing Supervisor or designee Signature Please list all discrepancies found during the inventory by medication name and quantity Indicate how the discrepancy was addressed in the action taken column If the discrepancy could not be resolved it must be reported to the pharmacy Action Taken CMHC Health Services Administrator Review Signature and Date Attach the print out slip from the Pyxis machine and send to Pharmacy Pyxis Mgr MC 2205 Last Review 06 10 Last Review 06 10 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION N
91. s unable to find sufficient information in available medication resources he she is obliged to check the medication with a second nurse a pharmacist and or physician If there is a question of drug compatibility clarify with the pharmacist or drug incompatibility chart e Psychoactive medication shall be supplied in tablet form as ordered by the clinician Tablet medication with the exception of enteric coated tablet or time released can only be crushed when ordered by the prescriber If the oral solid dosage form presents an administration problem the liquid form may be ordered e For the purpose of patient teaching insulin or other injectable medication may be self administered by the inmate approximately two weeks prior to release under the supervision of a licensed nurse All other insulin administration shall be by a licensed nurse o A licensed nurse shall verify the units and dosage in the insulin syringe and be present to observe and document the patient s self administration and observe the inmate s disposal of the used syringe into the sharps needle container Revision Date5 6 11 02 6 18 03 10 01 04 11 23 04 06 28 05 03 30 07 04 20 07 01 31 08 05 12 08 09 22 08 07 31 09 02 28 11 06 30 11 12 15 11 07 25 12 01 28 13 NUMBER D 2 19 Page 6 of 9 MEDICATION ADMINISTRATION DISTRIBUTION Self Administration of Medication Inmates shall be permitted to self administer medication Keep on Person
92. ss Name of person designated to pick up meds must be on the CDOC visitor list Note A separate Form HR 713A Inmate Personal Medication Receipt must be completed for controlled drugs Revision Dates 6 18 03 7 21 04 06 30 08 06 30 10 NUMBER D 2 15 5 Page 2 of 3 INMATE PERSONAL MEDICATION CMHC staff shall log the above processed packages into the department on the Form HR 713 Record of Receipt and Disposition of Inmate Personal Medication CMHC staff shall document the Form HR 713A Inmate Personal Medication Receipt serial number and the anticipated destruction date 30 days from receipt CMHC staff shall secure any controlled medications in a locked box or safe in the medication room and any non controlled medications in a designated receptacle in the medication room The yellow carbonless copy of the Form HR 713A Inmate Personal Medication Receipt shall be forwarded to the local custody element for inclusion into the inmate s master custody record The pink carbonless copy of the Form HR 713A Inmate Personal Medication Receipt shall be forwarded to the inmate 10 Any inmate personal medications received shall be secured in the CMHC _ medication room for periods not to exceed 30 days Inmates may designate on the inmate personal medication receipt a friend or family member to pick up the items prior to a 30 day point if their length of stay will exceed that Such designee must
93. t name and number allergies if any drug name drug strength quantity route discontinue date indications for use and any special instructions for administration for example start immediately start from contingency continue present dose until new dose arrives The prescriber name shall be documented through use of a CMHC approved name stamp or printed name as well as a signature A licensed nurse shall transcribe all medication orders The nurse shall initial each medication order transcribed as well as sign date and time the entire order entry Class Il Controlled Substances Class II controlled substances include but are not limited to Meperidine Demerol Methadone Dolophine Methylphenidate Ritalin and Morphine MS Contin In addition to writing the order on the Physician Order Sheet HR924 the prescriber shall complete including their DEA number the Schedule Il Prescription Form HR712 These forms shall be kept for 3 years The form HR 712 Schedule Il Prescription Form shall be scanned to the pharmacy along with the Physician Order Sheet HR 925 and followed by mailing of the hardcopy HR 712 Form HR 712 is not included in the HR The Pharmacy delivery manifest shall serve as the instrument to reconcile Class II drugs received from the Pharmacy with drugs ordered The pharmacist shall review this at the time of the monthly pharmacy inspection Revision Date 05 30 05 NUMBER D 2 03
94. t access privileges assigned to them These will be determined by the CMHC Pharmacy staff CMHC Nursing Supervisor on the basis of the individual s job responsibilities The standard user privileges by staff type are as follows e CMHC Staff Nurse Privileges Selected e CMHC Nursing Supervisor Privileges All CMHC Pharmacists are granted narcotic medication access for the purpose of monthly Unit Inspection Inventory The use of this function for medication removal is not allowed Pharmacy Console Access Levels CMHC Pharmacy Staff Only BASIC PHARMACY COMPUTER ACCESS Allows user to log in run reports view characteristics of the pharmacy based system PROFILE ORDER ACCESS Not applicable at this time USER CREATION PRIVILEGE Allows the ability to input permanent passwords PHARMACY MANAGER PRIVILEGES Allows the ability to manipulate various aspects of the system including the formulary and station set ups General Composition of the Pyxis Unit The Pyxis unit consists of six drawers Narcotic medications are stored in revolving carousel drawers having from 2 to 12 pockets that allow access to only one medication at a time Narcotics can also be stored in single pocket mini drawers that also allow access to only one medication at a given time Non narcotic medications are stored in matrix drawers or multi pocket mini drawers that allow the user access to all medications in a given drawer The Pyxis refers to all refrigerated items
95. t shall be reported to the CMHC Nursing Supervisor or designee immediately or in the absence of a CMHC Nursing Supervisor to the nurse in charge of the shift The CMHC Nursing Supervisor or the nurse in charge of the shift shall immediately notify the CMHC Health Services Administrator HSA Any nurse who had access to medication or who had administered medication during the period in question shall be required to stay at the site until the discrepancy is resolved or the HSA gives permission for the staff to leave The HSA shall notify the Unit Administrator designee and the CMHC Designated Director immediately of any potential or existing discrepancies An Incident Report page 1 shall be completed for each incorrect count when appropriate as well as a Form HR 714 Medication Administration Revision Dates 05 14 02 06 18 03 05 30 05 06 28 05 NUMBER D 2 01 Page 2 of 2 CONTROLLED SUBSTANCE COUNT Non Pyxis Facilities Variance Report Completed Form HR 714 shall be sent to the CMHC QI Administrator Accountability of all controlled substances shall be in accordance with federal and state statutes REFERENCES Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMH
96. the UCHC pharmacy e and is needed for continued treatment e orin certain cases when an inmate is admitted with a non formulary medication that a physician deems necessary for urgent inmate need such medication will be identified and administered by nursing staff Prior to administration of an inmate s personal medication e CDOC staff takes custody of any personal medication s from the inmate immediately upon admission to the CDOC facility e CDOC staff delivers this medication s to a CMHC staff member as soon as possible e The CMHC staff member assumes custody of the medication in accordance with provisions of CMHC Policy D 2 15 Inmate Personal Medication and assures that the inmate s personal medication s once identified is documented on Form HR 001 Intake Health Screening and HR Form 713 Record of Receipt and Disposition of Personal Medication e Aninmate s personal medication that is disapproved shall be confiscated inventoried and after 30 days destroyed in accordance with CMHC drug disposal policy Revision Dates 6 18 03 7 21 04 NUMBER D 2 16 Page 2 of 2 INMATE PERSONAL MEDICATION IDENTIFICATION e Aninmate Patient Personal Medication receipt shall be completed for each such seizure and a copy of the receipt provided to the inmate e For urgent situations only practitioners wishing to employ the inmate s personal medication into his her therapy during incarceration are responsible for
97. the patient See CMHC Policy D 2 20 Automated Medication Supply and Distribution System REFERENCES Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD Revision Date 06 28 05 UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 05 Page 1 of 1 NON MOBILE MEDICATION STORAGE CONTROLLED SUBSTANCES Effective Date 3 30 99 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that Class II controlled substances in small amounts not exceeding the quantity for efficient operation kept at any specific individual area or location in Connecticut Department of Correction CDOC facilities shall be stored in locked substantially constructed non portable and immobile metal cabinets or metal containers within another separate locked enclosure Class Ill IV and V controlled substance stock in small amounts not exceeding the quantity needed for normal efficient operation of each individua
98. to medical to discuss educate the inmate about the medication to determine if the inmate will resume taking the medication If the inmate does not agree to resume the medication a facility or covering prescriber shall be contacted as soon as possible and the referral documented on the MAR A signed Form HR 301 Refusal of Health Services shall be obtained and placed in the HR The patient encounter and referral shall be documented in the inmate HR If the inmate continues to refuse or not to show up to take the prescribed medication as specified above the inmate shall be referred to the prescriber a final time The inmate shall be informed of the expected benefits of the medication and the possible consequences resulting from not taking the medication If the inmate still refuses to take the medication the prescriber may consider discontinuing the medication until such time as the inmate commits to taking the medication The inmate shall be asked to sign Form HR301 Refusal of Health Services and the health services staff shall document the encounter in the HR Inmate Transfers The receiving facility shall circle the date day of transfer on the MAR and write the name of the receiving facility above the date If no MAR arrives with the inmate and a new MAR shall be generated the new MAR shall be marked duplicate and the above bullet documented noting that no MAR arrived from the sending facility If no medications arrive with the inm
99. treatment rooms for medical dental and mental health care are large enough to accommodate necessary equipment and fixtures and to permit privacy for inmate patients e Pharmaceuticals medical supplies and mobile emergency equipment e g defibrillator oxygen resuscitator are available e Adequate office space exists for administrative files separate secure storage of health records and writing desks e Private interviewing space that provides audio privacy desk s chairs and lockable file space are available for the provision of mental health services e Laboratory radiology inpatient or specialty services areas when provided on site are appropriately constructed and sufficient to hold equipment and records for the provision of these services e Sick call waiting areas are provided with seats and that drinking water and access to toilets is available e Inventories are maintained at a minimum on a daily basis to account for any items subject to abuse e g syringes needles scissors and other sharp instruments Revision Date 08 09 05 NUMBER D 3 01 Page 2 of 2 HEALTH SERVICES CLINIC SPACE EQUIPMENT AND SUPPLIES REFERENCES Occupational Safety and Health Administration OSHA Standards Prison Health Care Guidelines for the Management of an Adequate Delivery 1991 National Institute of Corrections U S Department of Justice Standards for Adult Correctional Institutions 4 4427 2003 American Correction
100. ty of Connecticut Health Center UCHC Correctional Managed Health Care CMHC staff shall ensure that controlled substances belonging to one specific inmate in a Connecticut Department of Correction CDOC facility shall not be borrowed or used for administration to any other inmate REFERENCES Standards for Adult Correctional Institutions 4 4378 2003 American Correctional Association Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Chicago IL Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title CDOC Director Health Services Daniel Bannish PsyD UNIVERSITY OF CONNECTICUT HEALTH CENTER CORRECTIONAL MANAGED HEALTH CARE POLICY AND PROCEDURES FOR USE WITHIN THE CONNECTICUT DEPARTMENT OF CORRECTION NUMBER D 2 07 Page 1 of 2 RECORD OF RECEIPT FOR CONTROLLED SUBSTANCES Effective Date 3 30 99 POLICY University of Connecticut Health Center UCHC Correctional Managed Health Care CMHC shall ensure that a record of receipt of controlled substances shall be maintained at each Connecticut Department of Correction CDOC facility PROCEDURE Non Pyxis Facilities No controlled substances are permitted at medical level 2 facilities For non pyxis medical level 3 facilities All controlled substance medications shall be inventoried by two licensed nurses when re
101. uration of the therapy shall begin with the approval date if the medication is on hand arrival date if the medication is delayed ef by the Non formulary Request Non Formulary Requests may be approved for up to a one year period and shall require a written order on the Physician Order Sheet every year to verify the need for continuing the medication 13 To renew a medication order draw a single line through the original order date and previous stop date and enter the renewal date and the new stop date 14 Renewal order dates may be rewritten on the MAR no more than 3 times A line shall be drawn through the old date and the new date for renewal written in ink 15 Medication orders shall not be prescribed for an indefinite time period The practitioner shall review medication regimens at specified intervals and indication to continue or discontinue shall be given prior to the current medication discontinuation date 16 Medication orders that are not specific shall not be prepared until clarification is received from the prescriber Staff shall make an effort to acquire order clarification in a timely manner Revision Dates 12 15 11 NUMBER D 2 19d Page 3 of 4 TRANSCRIPTION OF ORDERS 20 21 22 23 24 25 26 27 28 The hour s of medication administration shall be entered beside the medication order on the MAR using the generic military times 0800 is am 1200 is mid day 1600 is afternoon a
102. y by the nurse who makes or discovers the variance to the Physician and the CMHC Nursing Supervisor or nurse in charge of the shift Revision Dates NUMBER D 2 19c Page 3 of 3 MEDICATION VARIANCES e The medication variance shall be fully documented on CMHC Form HR 714 Medication Administration Variance Report e The nurse shall monitor and document the inmate s condition in accordance with instructions from the prescriber e The CMHC Nursing Supervisor shall complete and submit CMHC Form HR 714A Medication Variance Supervisor Follow Up Report to the HSA e The facility based QI Committee shall review the medication variance aggregate data monthly e The HSA shall submit these reports monthly to Central Ql e Significant medication variances shall be documented on Form CN 6602 Medical Incident Report in compliance with Administrative Directive 6 6 Reporting of Incidents REFERENCES Administrative Directive 8 3 Pharmacy Care 2007 Connecticut Department of Correction CMHC Pharmacy Manual Standards for Health Services in Prisons P D 02 2008 National Commission on Correctional Health Care Correctional Health Care Chicago IL Connecticut General Statutes Chapter 420b 420c CMHC Patient Safety System PSS User Manual Rev 3 2008 Approved UCHC CMHC Date Title CMHC Executive Director Robert Trestman MD PhD Title CMHC Director of Medical Services Mark Buchanan MD Title Director of He
103. ysician s Order Sheet The nurse shall document the date and time of the order the name of the medication the strength route of administration dose form duration or number of units frequency directions for use and prescriber name The nurse shall sign the order including title If the signature is illegible the nurse shall also print his her name LPNs may accept telephone orders from a physician or other authorized prescribers a An LPN shall not carry out a telephone order until an RN has reviewed and assessed the order inmate to ensure the order is consistent with the current plan of care b The RN shall date and sign that the order was reviewed All telephone orders shall be repeated to the physician for confirmation Medications administered according to CMHC approved Nursing Protocols shall be documented on the Physician s Order Sheet Form HR 925 and transcribed onto the inmate s Medication Administration Record using the procedure outlined in 3 above Revision Dates 12 15 11 NUMBER D 2 19d Page 2 of 4 TRANSCRIPTION OF ORDERS 7 A W 10 form shall not be considered the same as a Physician s Order Sheet Form HR925 Medications listed on a W 10 form shall be specifically ordered by a prescriber and documented on the Physician s Order Sheet Form HR925 8 The licensed nurse completes the appropriate transcription of the order onto CMHC Form HR 716 Medication Administration Record including the medicati

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