FAIRFAX COUNTY SHERIFF'S OFFICE SOP NUMBER: 430

STANDARD OPERATING PROCEDURE SUBJECT: PHARMACEUTICALS

I. PURPOSE

To prescribe procedures for the control and management of pharmaceuticals.

II. POLICY

It is the policy of the Fairfax County Sheriff's Office that:

A. The jail complies with all applicable state and federal regulations regarding prescribing,
dispensing, administering, and procuring pharmaceuticals.

B. The ADC has a contract with a pharmacy. A pharmacist is available for consultation as
needed and can also be available to make visits to the ADC.

C. All drugs are stored under proper conditions of sanitation, temperature, light, moisture,
ventilation, segregation, and security. Antiseptics, other drugs for eternal use, and
disinfectants are stored separately from internal and injectable medications. Drugs
requiring special storage for stability--for example, drugs that need refrigeration--are so
stored.

D. An adequate and proper supply of antidotes and other emergency drugs, and related
information, are readily available to the staff to meet the needs of the facility.

E. Quarterly pharmacy audits will be conducted by a pharmacist employed by the contract

pharmacy.

F. Written policies and procedures govern the pharmaceutical services.

III. PROCEDURE

A. A formulary is developed for both prescription and non-prescription medications used by

the facility.

B. Specific procedures for ordering, dispensing and administration and accounting for
pharmaceuticals are covered in SOP 424.

C. Medication brought into the Adult Detention Center.

1. Medications received from the Contract Pharmacy will be counted by a health

care provider and logged in the Pharmacy Received Book.

2. Any medications, including Schedule IV Drugs, that are in the possession of an

inmate at time of admission or delivered to the ADC by family or friends will be
turned over to a Health Care Provider and placed in secure storage. Schedule IV
Drugs will be counted and secured in the narcotics cabinet.

a. If an inmate is booked, they will receive the medications prescribed to

them by their personal physician. The medication will be continued for a
maximum of 5 days and the inmate’s name will be placed on the next
M.D. sick -call by the nurse admitting the inmate into the ADC.

1) The nurse admitting the inmate will start a medication

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FAIRFAX COUNTY SHERIFF'S OFFICE SOP NUMBER: 430
STANDARD OPERATING PROCEDURE SUBJECT: PHARMACEUTICALS

administration record with the name of the medication and

indicate that will be discontinued after 5 days.

2) The nurse should document if the inmate has brought in enough

medication for 5 days. This is necessary in order to receive the
medication from the contract pharmacy. If there is less than 5
days the ADC or CSB physician must be notified at the next sick
call.

3) The medication will be placed on the M.D. order sheet to be co-

signed by the MD or NP.

4) Inmates will be informed that the ADC physician/Nurse

Practitioner will review the medication and determine whether or
not they will be switched to a formulary version of the
prescription.

Provisions for these doses are:

a) the medication must be in an appropriately labeled

container with the inmates’ name on it
b) the labeled container has the name of the prescribing
physician
c) it is a current prescription, prior to the prescription being
approved by the ADC physician or psychiatrist.

b. The on-call physician will be consulted whenever an inmate arrives at the

ADC on prescribed schedule IV medications. These medications will not
be continued or discontinued without consulting the physician.

c. Properly labeled medications will be returned to inmates upon release.

d. Improperly labeled medications will be turned over monthly to the

Contract Pharmacy for destruction.

D. Disposal of Medications.

1. Medications no longer in use from the Contract Pharmacy will be counted and
returned to the pharmacy. This log will be signed off by two members of the
medical staff.

2. Improperly labeled or properly labeled medication left at the ADC by inmates are
sent to the contract pharmacy for destruction.

3. All narcotics and other controlled medications will be counted by two licensed
nursing staff, and logged on the “Medication Destruction Log”, removed from the
container and placed in diluted coffee ground material in a solid container. Once
the medications have dissolved, the container is sealed and placed into a
biohazard bag for destruction.

E. The following records are kept to ensure adequate control of and accountability for
medications.

1. Destruction Logs I and II (Attachment 1 and 2).

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FAIRFAX COUNTY SHERIFF'S OFFICE SOP NUMBER: 430
STANDARD OPERATING PROCEDURE SUBJECT: PHARMACEUTICALS

2. Inmate Medication Kardex (Attachment 3, separate entry).

2. Controlled Substance Sign Out Sheet (Attachment 4).

3. Controlled Substance Count (Attachment 5).

5. Sign Out Sheet (Needle/ Syringe) (Attachment 6).

F. The ADC provides maximum security storage of, and accountability for, DEA controlled
substances, needles, syringes, and abusable items.

1. Most needles and syringes are stored in a locked cabinet. A limited number are
available to the health care providers, however they must be signed out when
used (Attachment 6). This limited amount is counted at every shift change in the
Medical Section.

2. Controlled medications such as Diazepam, Tylenol #3, and Demerol, each have
a "Sign Out Sheet" (Attachment 4). At shift change the oncoming medical shift
will inventory all controlled medications by counting the amounts dispensed, if
any (as reflected on the individual "Sign Out Sheets" for each drug), and the
amounts remaining on hand. The total should agree.

a. If the totals agree, a member of the off-going and on-coming medical

shift will sign the "Controlled Substance Count Sheet" (Attachment 5).

b. If the totals do not agree and the count cannot be reconciled, the Medical
Administrator on-call will be notified. If the on-call Medical Administrator
is unavailable, the on-duty Shift Commander will be notified and an
incident report prepared by the off-going medical shift prior to departure
from the ADC. In such cases, the "Controlled Substance Count" sheet
will also be completed and annotated to indicate that a discrepancy
exists.

G. All prescription medications will be specifically ordered for an inmate by the Adult
Detention Center Physician, Psychiatrist, Dentist, or Nurse Practitioner. Such
medications will be labeled with the inmate's name for whom it is ordered. There are stop
dates indicated for behavior modifying medications and those subject to abuse. Prior to
renewal of a prescription, a re-evaluation is performed.

H. All medications are under the control of appropriate staff members. Inmates do not
prepare, dispense, or administer medication except as provided for in SOP 424,
Medication Administration Training. Refer to SOP 941, Medical Exams, Sick Call and
Self-Medication for medication administration in the Community Corrections Division.

I. Psychotropic medication (including tranquilizers) are used only in clinically indicated

cases, only as long as necessary, and are not allowed for disciplinary reasons.

J. Schedule of administration times, unless specifically ordered:

1. One time daily 11:00 a.m.

2. Two times daily 11:00 a.m. and 9:00 p.m.
3. Three times daily 6:00 a.m., 11:00 a.m. and 9:00 p.m.
4. Four times daily 6:00 a.m., 11;00 a.m., 5:00 p.m. and 9:00 p.m.

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FAIRFAX COUNTY SHERIFF'S OFFICE SOP NUMBER: 430
STANDARD OPERATING PROCEDURE SUBJECT: PHARMACEUTICALS

K. Inmates housed in the Alternative Incarceration Branch will be evaluated for keep-on-
person medication. The program is explained to the inmate and a contract for their
participation is developed and is signed by the inmate and a qualified health care
provider.

LISHAN KASSA STACEY A. KINCAID VERA J. GILES, BS, MSA

ADC MEDICAL DIRECTOR SHERIFF HEALTH SERVICES ADMINISTRATOR

Revised: May 2005, December 2005, January 2009, August 2010

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