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Policy And Procedures

Policies and Procedures Manual

Pharmacy Alternatives has Policies and Procedures that we follow which are written in accordance with Board of Pharmacy regulations and Pharmacy Best Practices. We will be happy to explain any policies and processes to your key users in your organization.

It is necessary for each customer facility to have its own policies and procedures for those medication processes that take place in your facility. For example, you may need to have policies on medication check-in, medication returns and disposal, access to medications, self-medication by your clients, medication administration processes, facility times of administration and other topics. These policies should be developed within the parameters of your facility practices and state and federal laws, and in accordance with those pharmacy policies that may apply.

For information about our policies and procedures pertaining to medication returns or medication disposal, please select one of the items below:

Medication Returns
Medication Disposal


Medication Returns (Click here for downloadable PDF.)

Policy:

Pharmacy Alternatives™ has identified a system for safe and efficient medication returns following a set of common best practices criteria for safety and quality standards in pharmacy.

Practice:

  1. RETURNS DUE TO PHARMACY ERROR: Any medication can be returned to the Pharmacy if the medication was sent in error to the consumer and the error was the fault of the Pharmacy. This is the ONLY instance in which a Controlled Medication can legally be returned to the Pharmacy.
  2.  

    1. If due to Pharmacy error, a delivered medication must be returned to Pharmacy Alternatives within 7 days of receipt by the client/facility.
    2. Pharmacy error would include situations such as:
      1. medication delivered to the consumer that had been previously discontinued and the pharmacy had been faxed an order stating this prior to the dispensing date
      2. medication delivered to the consumer that the consumer was never on
      3. medication that was not labeled correctly
      4. medication that was not in the correct form (full tabs sent instead of ½ tabs, pills sent instead of sprinkles, pills sent instead of liquid form, etc.)
      5. duplicate medication was sent

     

  3. The Consumer Change of Status Notification form should be faxed to the pharmacy EVERY TIME a consumer is transferred, discharged, passes away, or has a status change in their day programming or any other instance which would affect their medication administration, packaging, or delivery. Faxing this completed form before or immediately upon a status change will assist the pharmacy in providing more efficient and accurate medication delivery.
  4.  

  5. Medications CAN NOT BE RETURNED to the Pharmacy if any of the following conditions exist:
  6.  

    1. Medication has been used or opened
    2. Medications with partial contents that are not in pill form such as drops, creams, lotions, or inhalers
    3. Medications that come as a part of a multiple pack in which a part has been used or is missing such as Diastat rectal gel twin pack syringes for seizures
    4. Medications that require refrigeration (we cannot verify the integrity of the medication once it is dispensed and delivered)
    5. Medications that have been crushed, adulterated, disintegrated, or tampered with in any way
    6. Medication labeling and/or packaging has been altered or defaced and the identity of the drug, its potency, lot number, or expiration date are not legible
    7. The medication is expired or has an expiration date within 120 days
    8. The medication is a compounded drug

     

  7. Controlled Medications can not be returned to Pharmacy except as listed in #1 above. These must be disposed of according to federal and state laws in your area.
  8.  

  9. If a facility nurse/staff has a question about whether a medication can be returned to the pharmacy, he/she should call the Pharmacy prior to returning any medication to get clarification.
  10.  

  11. The pharmacy must receive written verification with all medications being returned including the reason for their return. Other additional information that is required includes: consumer name, Rx#, medication name, dosage, amount being returned, and the signature and contact number of the person returning the medication. A Medication Return Log has been provided with this policy. All medications being sent back to the pharmacy must be accompanied by a copy of this signed form. A copy should also be retained in the facility for documentation of all medication returns.
  12.  

  13. Once returned to the Pharmacy, the medication will be verified by a pharmacist for all identifying information and the determination of whether credit is due to the client will be decided.
  14.  

  15. If credit is due, the client will be credited any copay or other amount due.
  16.  

  17. Additionally, the payer source will be reimbursed the cost of the medication returned to the Pharmacy.
  18.  

  19. In accordance with HIPAA regulations, the medication label with the client's name will be removed and destroyed separately from any medication.
  20.  

  21. All medications that are not returned to the Pharmacy and are not being utilized by the client they are prescribed for should be destroyed according to federal, state, and local laws. See our policy on Medication Disposal for further information.
  22.  

  23. If a facility is disposing of excessive amounts of medication, it is the facility's responsibility to evaluate reasons for their increased pharmaceutical waste and to implement systems for decreasing their waste. The pharmacy can assist in providing suggestions for decreasing pharmaceutical waste through evaluation of ordering and usage procedures.
  24.  

  25. Each state is governed by federal, state, and local laws pertaining to pharmacy regulations and each facility should follow all laws and regulations pursuant to their specific state.


Medication Disposal (Click here for downloadable PDF.)

Policy:

Medication disposal should follow federal and state laws for all prescription, controlled, and over-the-counter medications.

Practice:

  1. Medications that are no longer needed by the client, have been discontinued, and are unable to be returned to the pharmacy should be disposed of according to applicable laws and guidelines.
  2.  

  3. The Office of National Drug Control Policy (ONDCP) and the Environmental Protection Agency (EPA) jointly released guidelines this year for disposal of prescription medications. Consumers are urged to continue flushing controlled substances. Controlled Substances must be destroyed so that they are unusable by another person to prevent diversion of the drugs.
  4.  

    1. Complete records of the controlled medications must be maintained by the facility including name of medication to be disposed, Rx number, dosage, number of pills or amount being disposed, reason for disposal, signature of RN, LPN, physician, pharmacist, or law officer disposing of medication, and a second signature of a witness. There must be "cradle to the grave" accountability for all controlled medications.
    2.  

    3. Controlled medication disposal documentation must be kept separately from non-controlled medication disposal documentation. Documentation must be easily retrievable.

     

  5. According to the 2007 Federal Prescription Drug Disposal Guidelines (see #2), prescription drugs other than Controlled Drugs, can ONLY be flushed down the toilet if the patient information specifically states to flush them. This is necessary to improve and maintain the healthy water systems in the U.S. by decreasing the amount of pharmaceutical waste which has been shown to cause biological impairment to wildlife and humans.
  6.  

  7. Since hospitals, clinics, physician offices, businesses, and other medical facilities fall under the EPA Hazardous Waste provision for disposal of pharmaceuticals, Pharmacy Alternatives will assume that ICF-MR and all waiver and supported living environments would fall under this category also (as it relates to #2).
  8.  

  9. Unused prescription and over the counter (OTC) medications that do not meet criteria for flushing or for return to the Pharmacy should be disposed of by:
  10.  

    1. Disposal into hazardous waste containers approved for pharmaceuticals which can either be:
      1. Mailed to a reverse distributor licensed to dispose of pharmaceutical waste, or
      2. Picked up at the facility by an approved reverse distributor
      3.  

    2. Cost of disposal via a reverse distributor is assumed by the specific facility disposing of the waste
    3.  

    4. Any other acceptable forms of disposal that do not involve flushing medications and are safe for the clients and staff

     

  11. Hazardous waste containers approved for disposal of pharmaceutical waste should be obtained through your facility's medical supplies vendors.
  12.  

  13. The facility must have a policy and procedure in place addressing accountability for all medications including controlled medications, prescription medications, and OTC medications.
  14.  

  15. Vitamins, minerals, and herbal supplements should be disposed of following the same procedure as OTC medications.
  16.  

  17. A Medication Disposal Log is included with this policy for facilities to use if needed.
  18.  

  19. If a facility is disposing of excessive amounts of medication, it is the facility's responsibility to evaluate reasons for their increased pharmaceutical waste and to implement systems for decreasing their waste. The pharmacy can assist in providing suggestions for decreasing pharmaceutical waste through evaluation of ordering and usage procedures.
  20.  

  21. Each state is governed by federal, state, and local laws pertaining to pharmacy regulations and each facility should follow all laws and regulations pursuant to their specific state.


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