LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 352.20 Interfacility Transfer of Medications
 
  PROCEDURES
  1. Interfacility Transfer of Medications
    1. Authorized Personnel shall utilize Sample Medications Inventory Log Sheet, Clinic Medication (Clinic-Stock) Inventory Log Sheet, Patient’s Own Medication Inventory Log Sheet, Expired Medications Inventory Log Sheet, and any other relevant Log Sheets needed to reconcile the transfer of medications and/or supplies at impacted DMH directly operated clinic.
    2. If interfacility medication transfer and inventory reconciliation occurs during business hours when clients are expected to come to clinic for medication administration, the registered nurse or psychiatric technician shall set aside scheduled client's medications to account for the deduction of inventory.  
    3. Prior to interfacility medication transfer from one clinic to another, authorized personnel shall:
      1. Reconcile and sign-off between on-site inventory needs, and
      2. Review against any administration or distribution that occurred during the inventory period or thereafter, if applicable.
    4. All temperature sensitive medications shall be transported utilizing appropriate temperature-controlled containers that can be monitored for temperature readings. The temperature reading shall be noted on the temperature log sheet prior to and at the time of delivery to the receiving clinic.
    5. The list of items that shall need to be transported during the interfacility medication transfer are all medications (expired and non-expired), refrigerated medications, and the pharmaceutical waste bin. Other items such as sharps containers, medical supplies and California State Board of Pharmacy compliance binders can be left in the clinic, unless there are extenuating circumstances which warrant the transfer or if the clinic moves to a different permanent location.
    6. The same processes noted above shall be documented for the delivery back to the originating clinic, if applicable.
    7. All reconciliation records of the interfacility medication transfer shall be provided to the clinic(s) involved and saved within the Pharmacy Department for a minimum of three (3) years.