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Post all licenses issued by the California State Board of Pharmacy and CLIA Certificate of Waiver so they are visible to the public.
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Ensure the Master Signature Sheet is available to record and maintain clinic personnel who have access to the medication storeroom.
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Keep DMH policies and procedures and Medication Storage Area Inspection Form in the medication room.
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Ensure pharmaceutical waste containers are available for proper disposition.
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Perform sample check on the Medication Administration Record (MAR) for recording and documentation of clinic-administered medications to clients.
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Check for proper storage of drug stocks to ensure that their integrity, stability, and effectiveness are maintained (i.e., required conditions of temperature, sanitation, classification separation, etc.).
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Check the medication refrigerator to ensure only medications are stored in the medication refrigerator. Medications shall not be stored in the same refrigerator with food or beverages or urine specimens in accordance with DMH Policy 306.18.
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Check for proper labeling of all medication containers.
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Check for outdated, deteriorated, and contaminated medications.
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Check to ensure that medications are stored according to manufacturers’ instructions and specifications.
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Check medication inventory records to ensure accuracy.
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Check for adherence to DMH Policy 352.12 Medication Security.
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Check clinic offices, group rooms, treatment rooms, or any areas outside of DMH-designated medication rooms for medications stored. Under no circumstances shall medications be stored outside of the secured medication room as per DMH Policy 352.14 Medication Storage.
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Check for prescription medications to ensure prescription medications labeled with a specific client name are not administered to a different client.
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Check and perform inventory counts for selected medication samples.
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Check for medications overstock and stock rotation.
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Record audit findings on the Medication Storage Area Inspection Form.
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Audit control team records are required to be kept on file for three (3) years at the clinic.
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A copy of the inspection record shall be kept in DMH Pharmacy Office.
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Provide in-service training at the clinics regarding audit control rounds as per the direction of the DMH Chief of Pharmacy/designee.
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Discuss audit rounds findings with the lead clinic nurse and supervising psychiatrist and make recommendations.
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Provide copies of audit rounds findings to the DMH Chief of Pharmacy/designee, DMH Chief of Nursing/designee, lead clinic nurse, program manager, and supervising psychiatrist for appropriate corrective action.
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Coordinate activities and cooperate with DMH Compliance, Privacy, and Audit Services as needed and answer questions regarding inspection findings.
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Perform special audit control activities under the direction of the DMH Chief of Pharmacy/designee.
