Medication Services

Idaho
Department of
Correction

Standard
Operating
Procedure

Division of
Education
and
Treatment

Operational
Services
Control Number:
401.06.03.089
Version:
1.1
Page Number:
1 of 5
Adopted:
8-8-2009
Reviewed:
8-8-2009

Title:
Medication Services

This document was approved by Dr. Mary Perrien, chief of the Division of
Education and Treatment, on 8/8/09 (signature on file).
BOARD OF CORRECTION IDAPA RULE NUMBER 401
Medical Care
POLICY STATEMENT NUMBER 401
Hospitalization, Institutional Clinical Services, and Treatment
POLICY DOCUMENT NUMBER 401
Hospitalization, Institutional Clinical Services, and Treatment
DEFINITIONS
Standardized Definitions List
Contract Medical Provider: A private company under contract with the Department to
provide comprehensive medical, dental, and/or mental health services to the incarcerated
offender population. A contract medical provider may include private prison companies and
other entities under contract with the Department to operate the Idaho Correctional Center
(ICC) and other out-of-state facilities housing Department offenders.
Facility Health Authority: The contract medical provider employee who is primarily
responsible for overseeing the delivery of medical services in an Idaho Department of
Correction (IDOC) facility.
Facility Medical Director: The highest ranking physician in an Idaho Department of
Correction (IDOC) facility.
Health Authority: The Department employee who is primarily responsible for overseeing or
managing the Department’s medical and mental health services. The health authority is
commonly referred to as the health services director.
Medication Administration Error: Any deviation from the ordered medication regimen for a
patient, to include administration errors such as (1) administering medications to the wrong
patient, (2) administering the wrong medication, (3) administering the wrong dosage or
strength of medication, (4) administering medications at the wrong time (5) administering an
extra dose of medication, or (6) omitting a dosage of medication.
Medication Room: A room where medications are stored and distributed.
Control Number:
401.06.03.089
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1.1
Title:
Medication Services
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Self-medication Program: A program that permits responsible offenders to carry and
administer their own medications. (Also known as Keep-on-Person Program.)
PURPOSE
The purpose of this standard operating procedure (SOP) is to establish procedures for
ensuring offenders are provided medication services that are clinically appropriate, timely,
safe, and sufficient to address the medication needs identified by the healthcare practitioner.
SCOPE
This SOP applies to all Idaho Department of Correction (IDOC) healthcare services staff,
offenders, contract medical providers, subcontractors, volunteers, and visitors.
RESPONSIBILITY
Health Authority
The health authority is responsible for:
• Monitoring and overseeing all aspects of healthcare services, and
• The implementation and continued practice of the provisions provided in this
SOP.
When healthcare services are privatized, he will also be responsible for:
• Reviewing and approving (prior to implementation) all applicable contract medical
provider policy, procedure, and forms; and
• Monitoring the contract medical provider’s performance, to include but not limited
to reviewing processes, procedures, forms, and protocols employed by the
contract medical provider to ensure compliance with all healthcare-related
requirements provided in respective contractual agreements, this SOP, and in
National Commission on Correctional Health Care (NCCHC) standard P-D-02,
Medication Services. (See section 3 of this SOP.)
Contract Medical Provider
When healthcare services are privatized, the contract medical provider is responsible
for:
• Implementing and practicing all provisions of this SOP, unless specifically
exempted by written contractual agreements;
• Ensuring that all aspects of this SOP and NCCHC standard P-D-02 are
addressed by applicable contract medical provider policy and procedure;
• Ensuring facility health authorities utilize all applicable contract medical provider
policy, procedure, forms, and educational information to fulfill all healthcare-
related requirements provided in this SOP, NCCHC standard P-D-02, or as
indicated in their respective contractual agreement(s); and
• Ensuring all applicable contract medical provider policy, procedure, and forms
are submitted to the health authority for review and approval prior to
implementation.
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401.06.03.089
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1.1
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Medication Services
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Note: Nothing in this SOP shall be construed to relieve the contract medical provider(s)
of any obligation and/or responsibility stipulated in respective contractual agreements.
Facility Medical Director
The facility medical director will be responsible for establishing and monitoring contract
medical provider prescriptive practices, including assignment of prescription privileges,
in accordance with State and federal laws and regulations.
Facility Health Authority
The facility health authority will be responsible for:
• Ensuring the presence of an adequate number of appropriately trained staff and
materials are available to meet the requirements of this SOP;
• Establishing and monitoring applicable contract medical provider policy and
procedure to ensure that all elements of this SOP and NCCHC standard P-D-02
are accomplished as required;
• Ensuring that medication services are included in the continuous quality
improvement (CQI) process, with emphasis on addressing trends noted in
offender concerns and grievances. (See SOP 401.06.03.006, Continuous Quality
Improvement Program.)
Table of Contents
General Rquirements ........................................................................................................... 3
1. Guidelines ...................................................................................................................... 3
2. Contract Medical Provider Procedures ........................................................................... 4
3. Compliance .................................................................................................................... 5
References ........................................................................................................................... 5
GENERAL REQUIREMENTS
1. Guidelines
• The facility medical director shall determine prescriptive practices in his facility.
• Prescription medications shall be administered or delivered to the patient only upon
the order of a physician, dentist, or other legally authorized individual.
• Medications shall be prescribed only when clinically indicated.
• Psychotropic and behavior modifying medications shall not be used for disciplinary
reasons.
• Offenders entering the facility who are on prescription medications shall continue to
receive the medication (or an acceptable alternate medication) without interruption,
as prescribed, and as clinically indicated.
Note: Doors to medication rooms shall remain locked at all times. Under no
circumstance shall the doors to medication rooms be left ajar, propped open, or blocked
in any way to prevent closing.
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2. Contract Medical Provider Procedures
At a minimum, contract medical provider procedures must address the following in detail:
• Storage of medications—All medications and supplies shall be stored in a manner
that is consistent with patient and staff safety, and State and federal laws and
regulations.
• Self-medication—The self-medication (keep-on-person) program must specify (1)
medications that are available for offender self-medication, (2) written instructions for
offenders to follow, and (3) all matters necessary to ensure that the program is safe
and effective.
• Medication administration errors—The evaluation of medication errors is critical
for identifying the immediate medical concerns of the patient and to help prevent
repeat errors. All medication errors shall be evaluated, documented, and maintained
on file for review.
Note: The error occurs only when the patient is directly involved. If the error is corrected
before the medication is administered, then the error shall not exist.
• Stock medication control—The ordering of medication for stock shall be controlled
and documented in a perpetual log tracking each dose of stock medication
distributed.
• Medication stop orders— Medications shall be administered to patients for the
amount of time specified by the ordering healthcare practitioner as defined by State
and federal laws and regulations. No medications shall run indefinitely due to lack of
specific orders.
• Medication administration record (MAR)—Medication administration records shall
be maintained for each offender who has been prescribed medications. The MAR
shall include patient name, IDOC#, date of birth (DOB), and allergies. The MAR shall
be maintained on a monthly basis and updated as medication orders are adjusted to
meet the healthcare needs of the offender. All orders shall include the prescribing
provider, medication, dose, frequency, and start and stop dates. The timely filing of
the MAR in the offender's healthcare record is of critical importance.
• Sterile parenteral products—Sterile parenteral products shall be prepared as
prescribed by the healthcare practitioner in a manner that ensures the product is free
from microbial or particulate contamination according to pharmacy practice.
• Medication for starter doses—Stock medication and pre-labeled stock medication
for immediate use shall be kept in a locked area. Access shall be limited to
appropriately credentialed health services personnel.
• Ordering and delivery of medications—The ordering or delivery of medications
shall be as prescribed, in a safe and efficient manner, and meet all State and federal
laws and regulations.
• Urgent and emergency medication needs—The Healthcare Services Unit shall
respond to urgent medication requests during working hours in a timely and
appropriate manner. Services will be available to provide emergency medications
and medication information on a 24-hour basis when clinically indicated.
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• Medication distribution system—The medication distribution system shall be a
per-patient packaging system. Medication will be distributed from a licensed central
pharmacy system on a regular basis.
• Discharge medications—Discharge medications and medical supplies that are
necessary for the continuity of care shall be distributed to offenders upon release
(two [2] weeks of medication, along with a prescription for two [2] additional weeks)
per NCCHC standard P-E-13, Discharge Planning, and the current contract.
Note: If the current contract changes, the requirements for discharge medications
may also change. As a result, the health authority must ensure the requirements for
discharge medications are kept up-to-date in this SOP.
3. Compliance
Compliance with this SOP and all related Department-approved protocols will be monitored
by the health authority (or designee) by using various sources to include: this SOP, clinical
practice guidelines, routine reports, program reviews, and record reviews.
The health authority (or designee) must conduct two (2) audits per year, per facility (or more
frequently as desired based on prior audit results). The audits must consist of monitoring
applicable contract medical provider and IDOC policy and procedures, applicable NCCHC
standards, and the review a minimum of 15 individual records.
REFERENCES
National Commission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons, Standard P-D-02, Medication Services
– End of Document –