LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 351.01 Controlled Substances (306.23)
 
Policy Category:  Clinical
Distribution Level:  Directly Operated
Responsible Party:  Pharmacy and Therapeutics Committee
 
Approved by Curley L. Bonds, MD, Chief Medical Officer
Reviewed and Approved by Pharmacy and Therapeutics Committee on January 31, 2024

 
I.  PURPOSE
 
To establish procedures for controlled substances stored in Los Angeles County Department of Mental Health (DMH) directly operated clinics, including sample medications and client's own medications.
 
II.  DEFINITION
 
Professional Director: A physician acting in their capacity as the medical professional supervisor in a clinic who is registered on the Board of Pharmacy clinic permit and is responsible for the safe, orderly, and lawful provision of pharmacy services with support from a consulting pharmacist.

Authorized Personnel: Psychiatrist, Nurse Practitioner, Pharm.D., Registered Nurse, Licensed Vocational Nurse and Psychiatric Technician
 
III.  POLICY
 
The purchase, storage, distribution, and accounting of controlled drugs shall be executed in accordance with all federal and State laws and standards of professional practice. Each clinic is responsible for compliance with this policy.
 
Controlled substance orders or prescriptions shall be placed by a psychiatrist, nurse practitioner, or pharmacist who possesses a current Drug Enforcement Administration (DEA) license. Verbal orders for controlled substances in clinic to nursing staff or psychiatric technicians are not allowed. 
 
Each clinic shall hold a current registration with the DEA and appropriate State license from the California Board of Pharmacy in order to dispense controlled substances. A Clinic DEA Registration is not required if only storing controlled substances dispensed to a specific patient by a retail pharmacy. Samples that are controlled substances are not allowed.
 
All controlled substances shall be stored in a locked cabinet within a secured medication room that is only accessible by authorized personnel.
 
Under no circumstances shall Schedule II controlled substances be dispensed by the clinics.
 
Disposal of expired controlled substances shall be in accordance with DMH Expired Mediation and Device Disposal Policy 352.08.
 
IV.  PROCEDURES
 
Procedures - Controlled Substances
 
V.  AUTHORITIES
 
VI.  ATTACHMENT