Clinical

Written policy defining scope of medication services (prescribing, monitoring, administration, storage, disposal).

Identification of clinical leadership responsible for medication oversight (Medical Director / NP / Pharmacist).

Credential verification and privileging for all prescribers and administering staff.

Annual review and approval of medication policies by medical leadership.

Medication Management Committee/Clinical Oversight Review Policy

Regulatory Compliance Policy (DEA, FDA, State Board)

Integration of medication management into risk management and performance-measurement plans (Section 1.G & 1.M).

Procedure for medication assessment and documentation before prescribing.

Verification of diagnosis and treatment plan alignment.

Allergy Documentation and Verification Policy

Clinical Decision Support Use Policy

Adverse Drug Event and Medication Error Policy

Polypharmacy Monitoring and Review Policy

Evidence-based guidelines to minimize polypharmacy and abuse.

PDMP (OARRS) checks for controlled substances.

Electronic prescribing (EPCS) security and record retention (Section 1.J).

Criteria for initiating, continuing, discontinuing medications (including MAT).

Informed consent for all prescribed medications, including off-label use.

Process for drug–drug interaction review and allergy screening.

Medication-Assisted Treatment (MAT) Protocols

Controlled Substance Prescribing and Diversion Control Policy

Medication error and adverse drug event (ADE) reporting process.

Policy for receipt and inventory of medications (including samples).

Locked, segregated storage for all medications and samples.

Separate storage for controlled substances and refrigerated medications.

Daily temperature and security monitoring logs.

Limited access policy with key or card control list and audit trails.

Monthly inventory counts and reconciliation procedure.

Expiration date tracking and removal procedure.

Safe transport between sites and sample accountability process.

Storage and Temperature Control Protocol

Medication Inventory and Security Policy

Medication Sample Management and Destruction Policy

Biologic and Injectable Administration SOPs

Medication Administration and Observation Protocol

Five Rights policy: right person, drug, dose, route, time.

Verification process before administration (two identifiers).

Documentation of each administration in the EHR (lot number if applicable).

Observation and monitoring post-administration (e.g., Vivitrol).

Sharps and biohazard disposal (OSHA/CARF 1.H).

Emergency response plan for adverse reactions (epi/anaphylaxis kit).

Controlled substance waste/destruction with witness documentation.

Education provided to person served on purpose, side effects, and follow-up.

Defined clinical monitoring parameters (vitals, labs, EKGs).

Schedule for medication review by prescriber.

Adverse reaction and side-effect tracking system.

Quality improvement indicators (error rate, ADE trends).

Periodic peer review of prescriber documentation (Section 1.I).

Medication education and competency training for staff.

Medication return and destruction (DEA-compliant if controlled).

Documentation of all disposal events and witness sign-off.

Recall notification and removal of affected medications.

Safe discontinuation/tapering protocol with client communication.

EHR templates for medication orders and MARs.

Medication logs for reconciliation, storage, and controlled substances.

Audit trail for all medication entries and changes.

Secure scanning of prescriptions and lab results.

Confidentiality compliance with HIPAA and 42 CFR Part 2.

CLIA-Waived POCT Policy

Confirmatory Toxicology Testing Procedure

External Lab and Imaging Result Management Policy

Critical Value and Abnormal Result Notification Policy

Medication Education and Informed Consent Policy

Client self-administration and storage policy

After-Hours and On-Call Coverage Policy

Client Medication Adherence and Monitoring Procedure

Medication Incident and Adverse Event Tracking Policy

Safety Event and Root Cause Analysis Procedure

Emergency Response and Crisis Medication Protocol

Infection Prevention and Exposure Control Plan

Environment of Care and Equipment Maintenance Policy

Medication Management Quality Review Policy

Performance Indicators and Data Reporting Procedure

Annual Quality Improvement Plan (QI) Policy

Integrated Medication Documentation Policy

Integrated Note Template Procedure (Assessment, Plan, Case Conference)

Abnormal Results and Follow-Up Documentation Policy

Shared Plan of Care Documentation Policy

Staff Training and Competency Policy

Medication Safety and Error Prevention Training

Orientation and Annual Refresher Requirements Policy

Delegation and Scope of Practice Policy

Integrated Behavioral and Physical Health Medication Coordination Policy

Collaborative Care and Case Conference Procedure

Information-Sharing and Consent Policy (HIPAA/42 CFR Part 2)

Closed-Loop Referral and Follow-Up Policy

Data-Sharing and Privacy Agreement Policy