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Policy Advisory

Policy Advisory MAP Policy 10-3 Controlled Substance Count

Date: 11/27/2020
Referenced Sources: MAP Policy 10-3 Controlled Substance Count

The Drug Control Program has amended MAP Policy 10-3 relative to Medication Security and Record Keeping for Schedules II-V. The Final MAP Policy 10-3, as amended, and the redlined policy.

Table of Contents

MAP Policy 10-3 Controlled Substance Count

                                                      ADVISORY

TO:                       Medication Administration Program Administrators and Registered Sites

FROM:                 David E. Johnson, Director, Drug Control Program

DATE:                 November 20, 2020

SUBJECT:          MAP Policy 10-3 Controlled Substance Count

Please be advised that the Drug Control Program has amended MAP Policy 10-3 relative to Medication Security and Record Keeping for Schedules II-V. These amendments clarify the frequency of required two-person counts and the circumstances under which a one-person count is permissible.

The Final MAP Policy 10-3, as amended, and the redlined policy, showing amendments, are included on the next page as Attachment A.

Attachment A

Final MAP Policy 10-3 (redlined changes accepted):

  1. Medication counts are to be conducted whenever control of the medication key is passed, including placement of the key into or removal from a lock box.
  1. All such medication counts are to be conducted by two licensed and/or Certified staff persons, unless all of the below conditions are met, in which case, the required count may be conducted by a single licensed/Certified staff person coming on or going off assignment. Necessary conditions include the following:
    1. A second licensed/Certified staff person is not scheduled to be on site when the responsibility of the control of the medication key needs to be passed, and
    2. The required two-person count has been conducted within the preceding 24 hours.
  1. After a single licensed/Certified staff person conducts a required medication count under the above conditions, the following steps must be undertaken:
    1. The single licensed/Certified staff person must sign the Countable Controlled Substance Book  and note that the count was conducted by a single person rather than two persons, as otherwise required, and
    2. At the first practical opportunity, and no later than 24 hours after the last two-person count was conducted, a required two-person count must be conducted.

Amended MAP Policy 10-3 (redlined changes):

Deleted: Red strikethrough; Inserted: Blue Bold

  1. Medication counts are to be conducted whenever control of the medication key is passed, including placement of the key into or removal from a lock box.(i.e., at the start and end of each shift/assignment).
  1. DPH recognizes that there are some situations where All such medication counts are to be conducted by two licensed and/or Certified staff persons, are not available at every change of shift.  In those instances, it is recommended that the unless all of the below conditions are met, in which case, the required count may be conducted by a single licensed/Certified staff person coming on or going off shift/assignment: conduct a count and sign the medication count book.
    1. A second licensed/Certified staff person is not scheduled to be on site when the responsibility of the control of the medication key needs to be passed, and
    2. The required two-person count has been conducted within the preceding 24 hours.
  1. After a single licensed/Certified staff person conducts a required medication count under the above conditions, the following steps must be undertaken:
    1. The single licensed/Certified staff person must sign the Countable Controlled Substance Book  and note that the count was conducted by a single person rather than two persons, as otherwise required, and
    2. At the first practical opportunity, and no later than 24 hours after the last two-person count was conducted, for a required two-person count must be conducted.
  1. Under no circumstances should a two-person count be conducted less than once every twenty-four hours.

Downloads for MAP Policy 10-3 Controlled Substance Count

Referenced Sources:
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