Mental Health Licensure and Certification Section
licy and Procedure list 10/14/2021
Policy Page Number Must be
11. Medications, including injections, shall be administered only by
licensed persons or by unlicensed persons trained by a registered
nurse, Pharmacist or other legally qualified person and privileged
to prepare and administer medications.
12. Client requests for medication changes or checks shall be recorded
and kept with the MAR file followed by an appointment or
consultation with a physician.
13. Upon discharge of a patient or resident, the remainder of their
drug supply shall be disposed of promptly unless it is reasonably
expected that the patient or resident shall return to the facility. In
such a case, the remaining drug supply shall not be held for more
than 30 calendar days after the date of discharge.
14. Medications shall be stored:
• in a securely locked cabinet in a clean, well-lighted,
ventilated room between 59º and 86º F.;
• in a refrigerator, if required, between 36º and 46º F. If the
refrigerator is used for food items, medications shall be
kept in a separate, locked compartment or container;
• separately for each client;
• separately for external and internal use;
• securely if approved by a physician for a client to self-
1. A 6-month drug review by a Psychiatrist or Pharmacist is required
if taking Psychotropic medications
2. Findings from drug review recorded in client record with a
corrective action plan.
3. Staff is responsible for informing M.D. of review results if medical
intervention is indicated.