LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 352.20 Interfacility Transfer of Medications (306.32)
 
Policy Category:  Clinical
Distribution Level:  Directly Operated
Responsible Party:  Pharmacy and Therapeutics Committee
 
Approved by Curley L. Bonds, MD, Chief Medical Officer, on Jan 04, 2023
 
I.  PURPOSE
 
This policy establishes interfacility medication transfers from one Los Angeles County Department of Mental Health (DMH) directly operated clinic to another during an emergency crisis.
 
II.  DEFINITIONS
 
Authorized Personnel: Registered nurses, physicians, nurse practitioners, pharmacists, clinical pharmacists, psychiatric technicians, pharmacy technicians

Clinic: Any DMH directly operated clinic

Emergency Crisis: A situation or event which places medication integrity or safety in jeopardy at a DMH directly operated clinic

Interfacility: A situation in which authorized personnel are utilized to transport medications from one licensed DMH directly operated clinic to another DMH directly operated clinic    
 
III.  POLICY
 
Clinic authorized personnel shall notify DMH Pharmacy Services of medications at risk of not being stored in accordance with manufacturer requirements at directly operated clinics within one hour in emergency crisis situations.
 
Interfacility medication transfers from one DMH directly operated clinic to another shall only occurs during an Emergency Crisis.
 
Only authorized personnel shall engage in interfacility medication transfers between clinics.
 
Only authorized personnel shall sign off on the inventory reconciliation log sheets.
 
All interfacility medication transfers shall adhere to current DMH Policy 352.11 Medication Delivery, 352.05 Clinic Medications Inventory, 352.12 Medication Security, and 352.14 Medication Storage.
 
All reconciliation records of the interfacility medication transfer shall be saved and kept for a minimum of three years at directly operated clinics.
 
IV.  PROCEDURES
 
Procedures - Interfacility Transfer of Medications
 
V.  AUTHORITIES
 
VI.  ATTACHMENT
 
No attachments are associated with this policy.