Advisory  COVID-19 - Virtual Two-Person Count

TO: Medication Administration Program Administrators and Registered Sites

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

DATE: June 15, 2021

SUBJECT: COVID-19 MAP Virtual Two-Person Count and Disposal of Countable Controlled Substances

COVID-19 continues to produce challenges for registered Medication Administration Program (MAP) Community Programs to comply with MAP Policy 10-03 Medication Security and Record Keeping for Schedules II-V, which requires two licensed or MAP Certified staff to conduct a medication count whenever control of the medication key is passed, and MAP Policy 10-05 Medication Security and Record Keeping for Schedules II-V Disposal, which requires two licensed or MAP Certified staff to dispose of controlled substances.

DPH’s Drug Control Program  is allowing a 90-day extension of this alternative process for complying with MAP Policy 10-03 and 10-5, using the Virtual Two-Person Countable Controlled Substances Count outlined on pages 2- 3, provided that a two-person count must be conducted in-person and on-site at least once every 7 days.

This alternative process may continue to be used until September 15, 2021 for the following MAP practices, but does not change the current requirement that two licensed or MAP Certified staff are required to conduct the count:

• Adding a newly prescribed countable medication into the count;
• Adding in a refill;
• Transferring the balance from a completed page to a new page, including;
  • two signatures at the bottom of the completed page; and
  • The same two signatures at the top of the new page;
• Disposal; see MAP Policy 10-5; and
• Two-person (in-person and on-site) count.

COVID-19 Virtual Two-Person Countable Controlled Substances Count

Virtual Counting – Conditions of Eligibility

1. In light of COVID-19, two licensed/Certified staff persons are not scheduled to be on-site when the responsibility of the control of the medication key needs to be passed;
2. A two-person count has been conducted in-person within the preceding seven days;
3. One licensed/Certified staff member is on-site; and
4. One licensed/Certified staff member is available remotely.

Virtual Counting – Required Equipment

To conduct a virtual two-person count with one on-site and one remote licensed/Certified staff person using FaceTime or other similar, secure virtual web-based platform (VWP):

1. Each staff member must have a wifi-enabled computer, laptop or smart phone with a microphone and a camera capable of generating a live video feed; and
2. The VWP must be downloaded on each staff member’s device prior to starting the count.

Virtual Counting – Process

Once connectivity of the VWP is established between the on-site and remote licensed/Certified staff members, the count should proceed as follows:

1. The on-site staff member will:
   • unlock the (double) key lock box;
   • remove all of the medication from the box; and
   • open the Count Book to the Index.
2. Both staff members (on-site and remote) will:
   • view the index page;
   • use the index as the guide; and
   • identify the first medication listed in the index to be counted.
3. The on-site staff member will:
   • obtain the corresponding blister pack; and
   • open the corresponding count sheet page.
4. Both staff members (onsite and remote) will:
   • view the count sheet page; and
   • view the pharmacy label.
   • the count sheet and the pharmacy label must include the following matching information:
     • the individual’s name;
     • the medication name;
     • the medication strength; and
     • instructions for use;
   • view the amount of tablets listed in the “amount” (left) column; and
   • view the number of tabs in the medication blister pack.
     • both staff members will confirm that these numbers agree.
   • examine the blister pack carefully for signs of tampering
     • remote staff will witness documentation of irregularities; and
     • on-site staff will notify the supervisor immediately of any irregularities.
5. If all information is in agreement, the on-site staff member will:
   • place the medication container back into the (double) key locked box.
6. Both staff members will repeat steps 2-5 until
   • all countable medications are accounted for; and
   • all countable medications are secured into the (double) key locked box.

Virtual Counting – Documentation of Process

1. The on-site staff member will document the completion of the virtual count on the Count Signature Sheet in the Count Book, including the following:
   • date/time count is complete;
   • confirmation that the count is correct;
     • note “Yes” or “No”;
   • on-site staff member signature; and
   • printed name of remote staff member
     • note “virtual count”
2. The remote staff member will send an email to the on-site staff member, confirming:
   • date/time count is complete;
   • confirmation that count is correct;
     • note “Yes” or “No”;
   • name of on-site staff member that was witnessed conducting the count; and
   • remote staff member’s name and contact information.
3. The on-site staff member will print and file the email in a Virtual Count Sheet Verification notebook, created on-site for this purpose, each time virtual verification is completed.

The above mentioned count process may be adapted to accommodate the other associated processes as well. If you have any questions please contact your DDS, DMH or DCF MAP Coordinator, who will make available Example COVID-19 Documentation for these virtual processes.