BOP Program Statement 6031.06 § 17

a. Procedures for clinicians. The following procedures will be followed for directly observed

therapy (DOT):

 The person administering the medication will identify each inmate by examining two

forms of identification (e.g., photo ID, date of birth, registration number, name, etc.).

 The inmate will be directed to take the medication by the prescribed administration route

while being observed directly by the staff member.

 The inmate will then show the empty dose cup and water cup (when applicable) to the

person conducting DOT before disposal.

 The inmate will be directed to open their mouth to show the medication has not been

“cheeked” or, if the medication is sublingual, that it is properly placed under the tongue

and has begun to dissolve before leaving the window.

 Medication administration will be promptly documented in the EHR upon completion.

 In restrictive housing units where wireless connectivity to the local network is available,

medication administration will be documented at the point of care in the EHR electronic

medication administration record (eMAR). Otherwise, medication administration will be

documented on a printed, paper MAR and scanned into the EHR.

 When using an automated dispensing cabinet (AMDC) (e.g., Pyxis), the individual

removing a controlled substance from the AMDC must be the same individual who signs

the eMAR except in cases of an emergency.

 When an inmate refuses to take a prescribed DOT medication, or is a “no-show,” that

decision is documented on the eMAR.

Persons administering DOT medications must follow all administrative restrictions, to include

crushing requirements, per Bureau National Formulary.

b. Procedures for non-health care clinicians. Any appropriately trained staff member (e.g.,

correctional officer, food services employee, education employee, etc.), who is willing and

competent to perform medication administration and distribution, may be permitted to distribute

or administer medications if the following requirements are met:

 The staff member completes the EMAR: EMR Fundamentals training available on the

HSD Health Informatics page of the Bureau’s intranet site to gain access to the EHR to

document pill line administration and medication distribution.

 The staff member completes AMDC access training available on the HSD Health

Informatics page of the Bureau’s intranet site.

 The institution has a locally established pill line and medication distribution role and

responsibilities orientation.

 The staff member has demonstrated competency as documented on the “Non-Health Care

Clinician (NHCC) Pill Line and Distribution Competency Assessment” utilizing the

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standardized, national competency form available on the HSD page of the Bureau’s

intranet site.

The institution will ensure its Pharmacy & Therapeutics (P&T) Committee reviews this

utilization of staff at each meeting, ensuring quality of care is maintained and medication errors

are addressed appropriately. All medication errors will be reported as required by Program

Statement Pharmacy Services.

The Regional Medical Director and Regional HSA will be consulted prior to an institution

utilizing a non-health care clinician for pill line and medication distribution. Approval

notification will be made to the Warden.