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Advisory Ruling

Advisory Ruling New Site Checklist-Medication Administration Program Sites

Date: 07/01/2021
Referenced Sources: Medication Administration Program (MAP)

MAP DPH Regulations are intended to address the medication administration needs of stable individuals who are living in Department of Mental Health; Department of Children and Families; adult Massachusetts Rehabilitation Commission; and adult Department of Developmental Services licensed, funded, or operated community residential programs that are their primary residences and/or are participating in day programs and short-term respite programs.

The Department of Public Health (DPH) Drug Control Program requires that Service Providers of these community programs register with the DPH Drug Control Program (DCP) for the purpose of storage of medications and authorizing non-licensed employees to administer and/or assist with the administration of medications.

Prior to issuing the MAP MCSR for a community program, the Service Provider must attest that the site for which the registration is being applied meets all established criteria for compliance as set forth in 105 CMR 700.003 (F) as well as M.G.L. c. 94C, the Controlled Substances Act and is ready to function as a MAP site, once the MCSR is issued (please see MAP Site Checklist below).

MAP Site / Checklist

A. Checklist Prior to Opening:

  1. Dedicated Key Lock-Medication Storage Area
  2. Dedicated Countable Controlled Substance Storage Container (with access to ‘Countables’ using two key locks)
  3. Drug Reference Material Plan (e.g., Drug Reference Manual (dated within last two years) and/or Medication Information Sheets for all prescribed medications for the individuals supported at the site (to be obtained after opening) **See on-line References Advisory 4-04-18
  4. Current MAP Curriculum-Responsibilities in Action (2020)
  5. Current MAP Policy Manual (Version 2010 9-01, Revised 1-01-15) and subsequent MAP Advisories.
  6. List of Emergency Contact Numbers - (One page document-general reference-(e.g., poison control, 911, pharmacy, etc.)-Copy posted near telephone
  7. Plan to address need for 24/7 MAP Consultants- (e.g. Pharmacy Service Contract Agreement, Service Provider Staff RN, etc.)
  8. Service Provider Policy Manual (with policies specific to MAP)
  9. Chain of Custody Tracking System:
    1. Medication Book/Record
    2. Countable Controlled Substance Book
    3. Pharmacy Ordering and Receiving Binder
    4. Controlled Substance Disposal Binder
    5. Medication Release Documents
      1. Leave-of-Absence (LOA) forms
      2. Transfer documents forms
  10. Medication Occurrence Report Forms Binder
  11. Staff Training Binder (Attendance Records, Training Content Materials, etc.
  12. Licensed nurses to administer medications and/or Trained MAP Certified program staff with training records on-site for MAP Certified staff including:
    1. MAP Certifications
    2. CPR cards
    3. First Aid cards

B. Submit completed MCSR Application and Attestation Document to DCP:

  1. Obtain Massachusetts Controlled Substances Registration (MCSR)

C. Checklist When Operational:

  1. Massachusetts Controlled Substance Registration (MCSR)-is readily accessible and posted in Medication Storage Area
  2. Drug Reference Material (e.g., Drug Reference Manual (dated within last two years) is on-site and/or Medication Information Sheets for all prescribed medications for the individuals supported at the site **See on-line References Advisory 4-04-18
  3. List of Emergency Contact Numbers- (with general reference, individual specific references, e.g., Health Care Providers’ contact information, MAP Consultants, etc.), and Service Provider Managerial/Supervisory staff contact information-Copy posted near telephone
  4. Medications received directly from the pharmacy by MAP Certified staff/licensed staff with Countable medications received in tamper-resistant packaging
  5. Medication Book/Record (Documents for Each Individual supported by MAP) is on-site, including
    1. Health Care Provider Orders and Protocols
    2. Medication Administration Records
    3. Medication Progress Notes/Narrative Notes
    4. Emergency Fact Sheets listing current medication(s) name, dose and frequency
    5. A current Medication List (if not included on Emergency Fact Sheet) including medication(s) name, dose, and frequency
  6. Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver is on-site (if applicable)
  7. Training competencies/Protocols (if applicable)

*Vital Signs

*Gastrostomy(G) tube and/or Jejunostomy (J) tube)

*Routes other than Oral


*Blood Glucose Monitoring *Hospice Care Services

*High Alert-Clozapine (Clozaril)

*High Alert-Warfarin Sodium (Coumadin)

*Epinephrine via Auto-Injection (EpiPen)

*Other specialized trainings

Table of Contents

Downloads for New Site Checklist-Medication Administration Program Sites

Referenced Sources: