(a) Policy. Written policies and procedures pertaining to pharmaceutical services, that are consistent with professional practices and in accordance with all applicable federal, state and local laws, shall be established and implemented.
(b) Management.
(1) All written policies and procedures for the proper management of pharmaceuticals shall be established by the Health Authority in accordance with all applicable law. This plan shall include, but not be limited to the following:
(i) a formulary specifically developed for both prescribed and non-prescribed medications stocked by the facility;
(ii) procedures which account for receipt, dispensation, distribution, administration, and disposal of medication;
(iii) periodic inventory of controlled substances as defined by the Drug Enforcement Administration of the United States Department of Justice;
(iv) periodic inventory of all other medication retained in a facility on a schedule established by the Health Authority to insure that medications do not expire;
(v) appropriate security and storage of all medications and medical supplies including needles and syringes; and
(vi) maintenance of adequate supply of all regularly used drugs.
(2) Access to prescription medication shall be limited to only those persons with written authority of the Health Authority or those designated by them. Prescription medication for inmates shall be prescribed, dispensed and administered only by physicians, physician's assistants, nurse practitioners, nurses, pharmacists or other health care personnel properly trained and in compliance with State and Federal law.
(i) Prescription medication may be prescribed, dispensed and administered only when clinically indicated and consistent with a treatment plan.
(ii) Controlled substances or drugs whose toxic dose is close to the therapeutic dose shall be administered in liquid or powdered form whenever possible and when clinically appropriate.
(iii) Non-prescription analgesic medication may be distributed by Correction Officers in the housing areas in accordance with written guidelines approved by the Health Authority, and the Department of Correction.
(3) All administered medication shall be documented and maintained on records satisfactory to the Health Authority and shall consist of the following:
(i) the name of the inmate;
(ii) the name of the dispenser;
(iii) the name of the prescriber;
(iv) the name of the drug;
(v) the time of day and date the medication is dispensed;
(vi) the date the prescription expires;
(vii) directions for administering the medication; and
(viii) other information deemed necessary by the Health Authority to facilitate proper use.
(4) All medication prescribed and dispensed to inmates shall be administered in accordance with the prescriber's written directions and only up to the expiration date of the specific item. The Health Authority shall write policies and procedures that insure the prompt availability of non-formulary drugs and continuity of medication between health service sites.
(5) No inmate may be prescribed a controlled substance for more than two weeks unless determined to be necessary by a physician or authorized health care personnel after a thorough re-evaluation of the inmate's condition. There shall be exceptions for 21 day methadone and 30 day phenobarbital protocols.
(6) Written policies and procedures will be developed by the Department of Correction and the Health Authority to insure that inmates on medications can receive them if they are scheduled to be in court or at another facility at the time that medications are administered.
(7) Policies and procedures, developed by the Health Authority shall be implemented to insure that inmates who refuse significant medications are counseled on the medical consequences of refusal. Inmates must be offered subsequent administration if re-prescribed by medical personnel.