At all Hillcrest programs controlled medications are stored in a manner that prevents unauthorized access and diversion. Access to controlled substances is restricted to authorized personnel. In order to minimize the risk of diversion and enable timely identification of potential problems, Hillcrest maintains strict accountability of controlled substances. This is accomplished through the following procedures:

 

• All controlled medications are stored in a locked container within the locked medication cart in the nursing station.
• Access is strictly limited to nurses on duty.
• A count of controlled substances will be conducted daily by two authorized staff, one serving as a witness to the count.
• Other controlled medications such as stimulants are included in the controlled and counted medications effective at all campuses by November 1, 2019.
• Medication count will take place as soon as possible after the morning med pass is completed and checked by the evening nurse if they are unable to count together for any discrepancies.  ASD count at the school can be done with the HA nurse daily Monday-Friday when there is school in session.
• If an error in count or signature occurs, draw one line through the error, write “error” and initial. Do not change any previously recorded documentation.
• If a discrepancy is noted the Head Nurse and Nursing Director will be notified immediately
• The Head Nurse on each campus will review the Controlled Substance Record on a weekly basis. They will initial the date reviewed.
• All controlled substances to be destroyed will be destroyed by two nurses according to HEC policy when the order is discontinued or the patient no longer utilizes the medication (e.g., pain medication for specific issue).

 

• When there are two nurses on duty :
  1. One nurse will conduct an inventory of all controlled medications on site.
  2. The second nurse will witness and verify the inventory count.
  3. The inventory count will be recorded on the agency’s Controlled Substance Record , which will be dated and signed by both nurses.
  4. The daily inventory count is reconciled with the previous day’s count and usage using the Controlled Substance Record form.

 

• When there is only one nurse on duty:
  1. The nurse on duty will conduct an inventory of all controlled medications on site.
  2. An authorized supervisory staff member who holds current medication certification (i.e., Supervisor or Assistant Supervisor) will witness and verify the inventory count. The authorized supervisory staff member will have no direct access to or contact with the controlled medications. He/she will only witness and verify the inventory count.
  3. The inventory count will be recorded on the agency’s Controlled Substance Record, which will be dated and signed by both the nurse and the authorized supervisory staff.
  4. The daily inventory count is reconciled with the previous day’s count and usage using the Controlled Substance Record form.

 

Commonly used controlled substances which need to be accounted for:

Alpraazolam – Xanax

Clonazapam- Klonopin

Codeine

Diazepam- Valium

Hydrocodone- Lortab-Vicodin

Lorazepam-  Ativan

Oxycodone- Percocet

All Stimulants including but not limited to:

Adderall

Methylphenidate

Concerta

Focalin

Tenex

Ritalin