Behavioral Health Standard 2.E – Medication Use


The organization implements a policy that identifies for each program the scope of medication services, including whether or not it directly provides medication:

  1. Control
  2. Administering
  3. Prescribing
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When the program provides medication control, administering, and/or prescribing, documented training and education regarding medications:

  1. Is provided to direct service personnel:
    1. At orientation
    2. At least annually
  2. Is provided in accordance with identified needs to:
    1. The persons served
    2. When applicable, family members or others identified by the persons served
  3. Includes:
    1. The purpose of the medication
    2. The benefits and risks associated with medication use
    3. Contraindications
    4. Side effects
    5. Missed doses
    6. Potential implications of diet and exercise when using medications
    7. Risks associated with medication use during pregnancy
    8. The importance of taking medications as prescribed, including, when applicable, the identification of potential obstacles to adherence
    9. The need for laboratory studies, tests, or other monitoring procedures
    10. Early signs that medication efficacy is diminishing
    11. Signs of nonadherence to medication prescriptions
    12. Potential drug reactions when combining prescription and nonprescription medications
    13. Instructions on self-administration, when applicable
    14. The expected course of use of medication, including discontinuation
    15. The availability of financial supports and resources to assist the persons served to obtain needed medications
    16. What to do in the event there is a question or concern about a medication the person served is taking or has been prescribed
  • ???


When the program physically controls medications, written procedures are implemented that address:

  1. Inventory
  2. Safe storage
  3. Safe handling
  4. Safe disposal
  5. The following, as applicable:
    1. Obtaining medications
    2. Transportation and delivery
    3. Packaging and labeling
    4. Self-administration
    5. Off-site use
    6. A verification process for medications brought to the program for a person served that includes for each medication:
      1. Accurate identification
      2. The amount/quantity of the medication brought to the program
      3. Proper dosing instructions
      4.  Instructions for use, including the method/route of administration
    7. How nonprescription medications for persons served will be approved for use within the program
    8. Return of surplus medications to the persons served upon transition/discharge
  • ???


When the program provides medication control, administering, or prescribing, documentation of all medications for each person served, including prescription and nonprescription medications, includes:

  1. The name of the medication
  2. The dosage
  3. The frequency
  4. Instructions for use, including the method/route of administration
  5. Contact information for the prescribing
    1. Name
    2. Telephone number
  6. When applicable, information on medications administered, including:
    1. The time the medication was administered
    2. Identification of the person administering
    3. Consideration of dose accepted or refused
  7. Observed and reported medication reactions
  8. PRN medication given to the person served, including the reason
  9. Medication errors
  • ???


When the program provides medication control or administering, it provides ready access to the telephone number of a poison control center to:

  1. The persons served
  2. Program personnel
  • ???


A program that provides administering or prescribing of medications implements written procedures that address:

  1. How medications are integrated into the individualized plan of the person served
  2. Active involvement of the persons served, when able, or members of the family when appropriate, in making decisions related to the use of medications
  3. Availability of consultation 24 hours a day, 7 days a week from a physician, pharmacist, or qualified professional licensed to prescribe
  4. Review of past medication use, including:
    1. Efficacy
    2. Side effects
    3. Adverse reactions
  5. Identification of alcohol, tobacco, and other drug use
  6. Use of over-the-counter medications
  7. Use of medications by children/youth in out-of-home placements, if applicable
  8. Use of medications by women of childbearing age, if applicable
  9. Use of medications during pregnancy, if applicable
  10. Special dietary needs and restrictions associated with medication use
  11. Necessary laboratory studies, tests, or other monitoring procedures
  12. Documented assessment of abnormal involuntary movements in persons served receiving antipsychotic medications, if applicable:
    1. At the initiation of treatment
    2. At a frequency that meets the needs of the persons served
  13. Coordination with the physician(s) providing primary care
  14. Review of medication use activities as part of the performance measurement and management system
  15. An evaluation of the risk of diversion
  16. Behaviors related to stockpiling of medication
  17. Actions to be taken in case of emergencies related to the use of medications
  18. How the persons served obtain the medications needed to promote desired treatment/service outcomes while in the program
  19. Management of biohazards associated with the administration of medications


APS does not prescribe medication: 2.E.7-9 does not apply