If the program maintains, administers, or dispenses medications, the medication distribution services shall be in conformance with all appropriate state and federal pharmacy laws and shall adopt written policies and procedures for the following:

1. (1)

   1. (A) The documentation of:

      1. (i) Handling;
      2. (ii) Observation and self-administration;
      3. (iii) Witnessed disposal process;
      4. (iv) Medication errors;
      5. (v) Adverse reactions; and
      6. (vi) Use of medication.
   2. (B) Chain of custody will be maintained at all times;

2. (2)

   1. (A) Medication errors and adverse reactions are to be reported to the Office of Alcohol and Drug Abuse Prevention following the Incident Reporting Policy.
   2. (B) The office will receive follow-up reports throughout the program’s process of investigation and bringing the incident to a close;

3. (3)

   1. (A) A list of prescription medications and over-the-counter medications to be kept in stock on units that dispense medication shall be developed.

   2. (B)

      1. (i) Both lists will be developed in conjunction with the program's physician who shall sign and date denoting his approval.
      2. (ii) Any future additions and deletions must follow the same procedure.
   3. (C) The medication list shall be reviewed at least annually;
4. (4) Programs that do not employ or contract with a medical doctor shall not maintain stocked prescription medications;
5. (5) The program shall use an effective inventory system to track and account for all prescription medications;
6. (6) A system is in place to monitor and to dispose of all outdated medication in compliance according to the program's disposal policy;

7. (7)

   1. (A) Medication orders may be given by telephone to licensed or registered nurse.
   2. (B) The orders must then be signed by the authorizing physician ordering the medication within seventy-two (72) hours;

8. (8)

   1. (A) Medications shall be stored at appropriate temperatures based on the manufacturer’s product inserts.
   2. (B) Medications requiring refrigeration shall be stored in a locked compartment separate from food;
9. (9) External use medications in liquid, tablet, capsule, or powder form shall be stored separately from medications for internal use;
10. (10) Urine or blood samples shall not be stored with food or medicines;

11. (11)

    1. (A) The program shall keep all prescriptions and nonprescription medications, syringes, and needles in locked storage.
    2. (B) Medications, syringes, and needles shall be accessible only to staff who are authorized to provide medication; and
12. (12) Used needles and syringes shall be placed in secure, rigid, puncture-proof containers and disposed of according to United States Occupational Safety and Health Administration hazardous waste standards.