LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  POLICY 352.08 Expired Medication and Device Disposal
 
  PROCEDURES
  1. Expired medications shall be quarantined and the following information shall be logged in the disposal record or by electronic documentation in automated medication dispensing system:
    1. Date of disposal
    2. Client Name, if applicable
    3. Medication name
    4. Medication strength
    5. Quantity disposed
    6. Prescription number, if applicable
    7. Staff initials
    8. Witness initials for patient's own medications and controlled substances
  2. Disposal of unused, unwanted, and expired medications/controlled substances:
    1. Stock medications distributed to DMH directly operated programs from DMH Pharmacy:
      1. Only authorized personnel shall transfer stock medications to DMH Pharmacy at least two (2) months prior to their expiration date so that DMH Pharmacy can obtain credit from the reverse distributor or dispose of in a pharmaceutical waste receptacle in a secured medication room
        1. The DMH Chief of Nursing and DMH Chief of Pharmacy shall designate personnel responsible for transporting unused, unwanted, and expired medications to DMH Pharmacy Services
      2. The DMH Chief of Pharmacy or his/her designee shall dispose of medications in accordance with DMH Pharmacy Reverse Distribution Policy 352.16
      3. Inventory shall be adjusted to reflect changes
      4. Records of medication transfers shall be kept for three (3) years
    2. Medications dispensed to a specific client by a retail pharmacy:
      1. Labels containing identifying client information shall be placed in a secure shredding bin
      2. A disposal record shall be completed with second authorized personnel serving as witness
      3. The unused, unwanted, or expired medication shall be disposed of in a pharmaceutical waste receptacle in a secured medication room or through Drug Take-back locations
      4. Inventory changes shall be documented
      5. Records of waste pick-up shall be kept on record for three (3) years
      6. Upon discovery of any tampered pharmaceutical waste receptacles, clinic staff shall report the incident to the supervising psychiatrist, DMH Chief of Nursing, and DMH Chief of Pharmacy and file an incident report in accordance with DMH Suspected Criminal Activity Including Employee Theft and Misappropriation of Funds Policy 605.03
    3. Sample medications
      1. The disposal shall be documented
      2. The unused, unwanted, or expired medication shall be disposed of in a pharmaceutical waste receptacle in a secured medication room or through Drug Take-back locations
      3. Inventory changes shall be documented
      4. Records of waste pick-up shall be kept on record for three (3) years
      5. Upon discovery of any tampered pharmaceutical waste receptacles, clinic staff shall report the incident to the supervising psychiatrist, DMH Chief of Nursing, and DMH Chief of Pharmacy and file an incident report in accordance with DMH
    4. Controlled substances
      1. Controlled substances shall be placed in a controlled substances waste receptacle secured to the wall by brackets. The disposal shall be documented with second authorized personnel serving as witness.
      2. Upon discovery of any tampered controlled substances waste receptacle, clinic staff shall report the incident to the supervising psychiatrist, DMH Chief of Nursing, and DMH Chief of Pharmacy and file an incident report in accordance with DMH Policy 605.03
      3. Inventory changes shall be documented
      4. Records of waste pick-up shall be kept on record for three (3) years
      5. Upon discovery of any tampered controlled substances waste receptacle, clinic staff shall report the incident to the supervising psychiatrist, DMH Chief of Nursing, and DMH Chief of Pharmacy and file an incident report in accordance with DMH Suspected Criminal Activity Including Employee Theft and Misappropriation of Funds Policy 605.03