PURPOSE: This rule describes training and procedures for the proper storage, use and administration of medications in Alcohol and Drug Abuse Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs. (1) General Guidelines, Policies and Practices. The following requirements apply to all programs, where applicable.

1. (A) The organization shall assure that staff authorized by the organization and by law to conduct medical, nursing and pharmaceutical services do so using sound clinical practices and following all applicable state and federal laws and regulations.
2. (B) The organization shall have written policies and procedures on how medications are prescribed, obtained, stored, administered and disposed.
3. (C) The organization shall implement policies that prevent the use of medications as punishment, for the convenience of staff, as a substitute for services or other treatment, or in quantities that interfere with the individual’s participation in treatment and rehabilitation services.

4. (D) The organization shall allow individuals to take prescribed medication as directed.

   1. 1. Individuals cannot be denied service due to taking

prescribed medication as directed. If the organization believes that a prescribed medication is subject to abuse or could be an obstacle to other treatment goals, then the organization’s treatment staff shall attempt to engage the prescribing physician in a collaborative discussion and treatment planning process. If the prescribing physician is nonresponsive, a second opinion by another physician may be used.

1. 2. Individuals shall not be denied service solely due to not

taking prescribed medication as directed. However, a person may be denied service if he or she is unable to adequately participate in and benefit from the service offered due to not taking medication as directed.

1. (2) Medication Profile. Where applicable, the individual’s record shall include a medication profile that includes name, age, weight, current diagnosis, current medication and dosage, prescribing physician, allergies to medication, non-prescription medication and supplements, medication compliance; and other pertinent information related to the individual’s medication regimen.
2. (3) Prescription of Medication. If a program prescribes medications, there shall be documentation of each medication service episode including description of the individual’s presenting condition and symptoms, pertinent medical and psychiatric findings, other observations, response to medication, and action taken.

3. (4) Medication Administration and Related Requirements. The following requirements apply to programs that prescribe or administer medication and to those programs where individuals self-administer medication under staff observation.

   1. (A) Staff Training and Competence. The organization shall ensure the training and competence of staff in the administration of medication and observation for adverse drug reactions and medication errors, consistent with each staff individual’s job duties.

      1. 1. Staff whose duties include the administration of

medication shall complete Level I medication aide training in accordance with 19 CSR 30-84.030. This requirement shall not apply to those staff who—

1. A. Have prior education and training which meets or

exceeds the Level I medication aide training hours and skill objectives; or

1. B. Work in settings where clients self-administer their

own medication under staff observation.

1. 2. Staff whose duties are limited to observing clients

self-administer their own medication or to documenting that medication is taken as prescribed shall have available to them a physician, pharmacist, registered nurse or reference material for consultation regarding medications and their actions, possible side effects, and potential adverse reactions.

1. 3. Staff whose duties are limited to observing clients

self-administer their own medication or to documenting that medication is taken as prescribed shall receive education on general actions, possible side effects, and potential adverse reactions to medications.

1. (B) Education. If medication is part of the treatment plan, the organization shall document that the individual and family member, if appropriate, understands the purpose and side effects of the medication.
2. (C) Compliance. The program shall take steps to ensure that each individual takes medication as prescribed and the program shall document any refusal of medications. A licensed physician shall be informed of any ongoing refusal of medication.
3. (D) Medication Errors. The program shall establish and implement policies defining the types of medication errors that must be reported to a licensed physician.
4. (E) Adverse Drug Reactions. A licensed physician shall be immediately notified of any adverse reaction. The type of reaction, physician recommendation and subsequent action taken by the program shall be documented in the individual’s record.

5. (F) Records and Documentation. The organization shall maintain records to track and account for all prescribed medications in residential programs and, where applicable, in nonresidential programs.

   1. 1. Each individual receiving medication shall have a

medication intake sheet which includes the individual’s name, known allergies, type and amount of medication, dose and frequency of administration, date and time of intake, and name of staff who administered or observed the medication intake. If medication is self-administered, the individual shall sign or initial the medication intake sheet.

1. 2. The amount of medication originally present and the

amount remaining can be validated by the medication intake sheet.

1. 3. Documentation of medication intake shall include over-

the-counter products.

1. 4. Medication shall be administered in single doses to the

extent possible.

1. 5. The organization shall establish a mechanism for the

positive identification of individuals at the time medication is dispensed, administered or self-administered under staff observation.

1. (G) Emergency Situations. The organization’s policies shall address the administration of medication in emergency situations.

   1. 1. Medical/nursing staff shall accept telephone medication

orders only from physicians who are included in the organization’s list of authorized physicians and who are known to the staff receiving the orders. A physician’s signature shall authenticate verbal orders within five (5) working days of the receipt of the initial telephone order.

1. 2. The organization may prohibit telephone medication

orders, if warranted by staffing patterns and staff credentials.

1. (H) Periodic Review. The organization shall document that individuals’ medications are evaluated by qualified staff at least every six (6) months to determine their continued effectiveness.
2. (I) Individuals Bringing Their Own Medication. Any medication brought to the program by an individual served is allowed to be administered or self-administered only when the medication is appropriately labeled.
3. (J) Labeling. All medication shall be properly labeled. Labeling for each medication shall include drug name, strength, dispense date, amount dispensed, directions for administration, expiration date, name of individual being served, and name of the prescribing physician.

4. (K) Storage. The organization shall implement written policies and procedures on how medications are to be stored.

   1. 1. The organization shall establish a locked storage area

for all medications that provides suitable conditions regarding sanitation, ventilation, lighting and moisture.

1. 2. The organization shall store ingestible medications

separately from noningestible medications and other substances.

1. 3. The organization shall maintain a list of personnel who

have been authorized access to the locked medication area and who are qualified to administer medications.

1. (L) Inventory. Where applicable, the organization shall implement written policies and procedures for:

   1. 1. Receipt and disposition of stock pharmaceuticals must

be accurately documented;

1. 2. A log shall be maintained for each stock pharmaceutical

that documents receipts and disposition;

1. 3. At least quarterly, each stock pharmaceutical shall

be reconciled as to the amount received and the amount dispensed; and

1. 4. A stock supply of a controlled substance must be

registered with the Drug Enforcement Administration and the Missouri Department of Health, Bureau of Narcotics and Dangerous Drugs.

1. (M) Disposal. The organization shall implement written procedures and policies for the disposal of medication.

   1. 1. Medication must be removed on or before the expiration

date and destroyed.

1. 2. Any medication left by an individual at discharge shall

be destroyed within thirty (30) days.

1. 3. The disposal of all medications shall be witnessed and

documented by two (2) staff members. AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed April 15, 2002, effective Nov. 30, 2002. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980.