LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 352.05 Clinic Medications Inventory
 
  PROCEDURES
  1. For programs utilizing an Automated Medication Dispensing System (e.g. Pyxis System)
    1. Upon receipt of medications procured by DMH Pharmacy, directly operated clinic nurse(s) or psychiatric technicians(s) shall record inventory changes on the Medication Log.
    2. Upon administration of medication to clients, directly operated clinic nurses, psychiatric technicians, psychiatrists, or pharmacists shall document administration in accordance with DMH Policy 352.10 Medication Administration.
       
  2. For programs NOT utilizing an Automated Medication Dispensing System (e.g. Pyxis System)
    1. Upon receipt of medications procured by DMH Pharmacy, directly operated clinic nurses or psychiatric technicians shall record inventory changes on the Clinic Stock Medication Log.
    2. Upon receipt of medications from pharmaceutical sales representatives, directly operated clinic nurses or psychiatric technicians shall record inventory changes on the Sample Medication Log.
    3. Upon receipt of medications from retail pharmacies delivered for clients, directly operated clinic nurses or psychiatric technicians shall record inventory changes on the Patient's Own Medication Log.
    4. Upon receipt of controlled substance medications from retail pharmacies delivered for clients, directly operated clinic nurses or psychiatric technicians shall record inventory changes on the Patient's Own Controlled Substance Medication Log.
    5. Upon administration of medication to clients, directly operated clinic nurses, psychiatric technicians, psychiatrists, or pharmacists shall record and deduct amount from appropriate inventory log, and document administration in accordance with DMH Policy 352.10 Medication Administration.
  3. For clinic stock medications that will be dispensed to clients, prescribers shall affix medication label with information required under Business and Professional Code 4076 and all packaging requirements of good pharmaceutical practice, including the use of childproof containers.
     
  4. Expired medications shall be removed from stock and quarantined in accordance with DMH Expired Medication and Device Disposal Policy 352.08. Inventory shall be adjusted on the appropriate log.
     
  5. In accordance with DMH Suspected Criminal Activity Including Employee Theft and Misappropriation of Funds Policy 605.03, the following incidents shall be reported within 24 hours of discovery via Security Incident Report and to the supervising psychiatrist, DMH Chief of Nursing, DMH Chief of Pharmacy/designee, and Compliance, Privacy, and Audit Services:
    1. Missing or unaccounted medications due to suspected theft.
    2. Missing or tampered medication log entries.