Policy & Procedure: Controlled Substances Part 1

Controlled Substances Part I: Receipt & Storage

Controlled substances require extra attention for everything from ordering, receipt and recordkeeping to actually dispensing the medication. For receiving and storing these medications, keep the following basics in mind:

1. Your pharmacy can only dispense controlled substances after receiving a written prescription.

This also means that the medication will only be delivered to an assisted living community after the pharmacy has the prescription in hand. In an emergency your pharmacy may prepare and deliver a schedule II controlled med in response to a telephone order from the physician, as long as the written prescription is ready and waiting for them when they deliver. Otherwise, your pharmacy is legally required to not deliver the medication.

2. No refills.

If your resident needs to continue receiving a controlled medication, they’ll need a new prescription from their doctor. Requests for a new prescription should be made 7-10 dose days before the current supply runs out in order to avoid missing a dose. For example, if you have a full card of 30 oxycodone and the resident takes two tablets, three times daily, it’s time to request another order.

3. Keep detailed records.

Every time your community receives a new controlled medication, create a controlled drug administration record. This record must be updated every time you receive a new supply of the same medication for the same resident and must contain the following:

• Name of the resident

• Physician/prescriber

• Prescription number

• Drug name, strength, dosage form and route of administration

• Quantity ordered

• Quantity received

• Date received

• Name of the person who actually received the medication supply

• If the medication is stored in the resident’s apartment or room, the resident’s or caregiver’s acknowledgment that they received the medication

4. Lock them up and guard the key

Washington State requires all controlled medications to be stored in such a way that no resident can access another resident’s medication.

When schedule II, III, IV and V medications are stored in a resident’s apartment or room, they must be stored with the resident’s other medications in a designated and locked storage area.

Scheduled II and III medications that are managed by Assisted Living must be doubly locked. This means that they are stored in a designated, locked cabinet or safe set apart from all other medications and that this cabinet or safe can only be accessed with a key that only authorized personnel can access. (Some companies/communities require CIV and CV to be under double lock as well. Consult with your own policies and procedures.)

Controlled substances can not be returned to the pharmacy under federal law.

For more information on how to handle controlled substances, visit the Washington State Legislature’s website.