LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 352.09 Medically Supervised Administered Drugs
 
Policy Category:  Clinical
Distribution Level:  Directly Operated
Responsible Party:  Pharmacy and Therapeutics Committee
 
Approved by Curley L. Bonds, II, MD, Chief Medical Officer, on Dec 11, 2023
 
I.  PURPOSE
 
To establish the policy and procedures in the Los Angeles County Department of Mental Health (DMH) for medically supervised administered drugs at directly operated programs.    
 
II.  DEFINITIONS
 
Medically Supervised Administered Drugs (MSAD): Medications that require administration in a clinical setting under medical supervision or require administration by a healthcare professional.

Clinic: Any DMH directly operated program.

Authorized Personnel: Registered nurses, licensed vocational nurses, psychiatric technicians, psychiatrists, nurse practitioners, and clinical pharmacists.

Prescription MSAD:
MSAD dispensed by retail pharmacies for a specific client.
 
III.  POLICY
 
Under no circumstances shall MSAD be:
  • Directly dispensed or given to a client or caregiver for home, shelter, hospital or clinic administration.
Under no circumstances shall a prescription MSAD be:
  • Distributed to anyone;
  • Transferred to another client;
  • Loaned to another client;
  • Sold to anyone; nor
  • Returned to a dispensing pharmacy.
Authorized Personnel shall administer MSAD only when directly sent from retail, community pharmacy, manufacturer, distributor, or directly operated DMH program.

DMH Staff shall not accept or administer MSAD to clients if brought in by client or caregiver.

Authorized Personnel shall direct client to dipose any MSAD that is directly dispensed or given to the client or caregiver due to potential for compromised integrity of the MSAD.   

MSAD may be transferred to a non-DMH facility with client’s or client’s caregiver’s verbal agreement, if the following conditions are met:
  1. Non-DMH facility sends a representative with a proper medication storage container to retrieve the dose
  2. Proper disposition documentation is completed within Patient’s Own Medication Log
    • Name of licensed medical provider picking up MSAD
    • Work phone number of licensed medical provider
    • Name of non-DMH healthcare facility
    • Date and time of when dose was released
    • Signature of licensed medical provider picking up MSAD
IV.  PROCEDURES
 
No procedures are associated with this policy.
 
V.  AUTHORITY
 
DMH Administrative Directive
 
VI.  ATTACHMENT
 
No attachments are associated with this policy.