REFUGE HOUSE, INC.

PURPOSE:

To operationalize FC-MED-01 Medication Management Policy by specifying who does what, when, where, and how to ensure every medication a child in care receives is consented to, correctly administered, securely stored, documented within 24 hours, and monitored — and to document the Pulse medication system and the automated reminder/escalation service that support these duties.

RELATIONSHIP BETWEEN POLICY AND PROCEDURE:

FC-MED-01 establishes the governing commitments; this procedure provides the implementation steps and the technology workflow. Where this procedure references a Pulse screen or an automated job, those are the current operational mechanisms supporting the policy and are subject to ongoing enhancement.

RESPONSIBILITY:

• Foster Parent / Caregiver: administers and logs each dose; stores medication securely; reports errors, refusals, and side effects.
• Case Manager: reconciles the medication list; reviews logs; coordinates refills and changes; receives reminder/escalation notices; completes ISP Addendums and error/consent documentation; submits appointment forms.
• Program Director: receives next-day escalation notices; oversees unresolved overdue logs and remediation.
• Treatment Director / Prescribing Health-Care Professional: clinical oversight; quarterly psychotropic evaluation.
• Compliance & CQI: monitors the medication compliance dashboard; runs trend and CQI review.
• Registered Nurse (as applicable): consults on complex/medically fragile medication protocols.

IMPLEMENTATION GUIDANCE:

The Pulse medication dashboard and the refugehouse-checkin reminder/escalation service described in Sections 4, 5, and 12 are operational and in use; enhancements continue. Statements about these systems describe the mechanism that supports compliance with 26 TAC §749.1541(b) — they are not a representation that documentation is always complete. The source of truth for the reminder logic, thresholds, and message templates is the jduarte-refugehouse/refugehouse-checkin repository; this procedure summarizes it and must be updated if that implementation changes.

PROCEDURE:

1. MEDICATION INTAKE AND RECONCILIATION

2. ADMINISTRATION AND SAME-DAY LOGGING

3. CUMULATIVE MEDICATION RECORD — REQUIRED CONTENT

4. AUTOMATED REMINDERS AND ESCALATION (refugehouse-checkin)

The reminder/escalation service prompts caregivers to complete logging before the 24-hour deadline and escalates incomplete logs to case management and program leadership. Recipients are configured in the service (roles below; configured addresses are maintained in the check-in service config, not in this document).

5. STAFF "LOG ON BEHALF" OVERRIDE (with audit trail)

6. MEDICATION ERRORS AND LABEL ERRORS

SSCC-OCOK — addition start (provider-specific; remove this block if the OCOK contract ends)

For an OCOK-placed child, a missed, rejected, or erroneous medication dose is also handled as a Serious Incident: the assigned worker completes and submits a Serious Incident Report to seriousincidents@oc-ok.org and to the assigned Supervisor and Permanency Director within 24 hours, and logs the event on the youth's medication log. Administration, storage, and destruction follow DFPS Policy 11300 (Medication), and OCOK requires use of the OCOK Prescription Medication Log and OCOK Non-Prescription Medication Log. Cross-reference: FC-SIR-01 Serious Incident Reporting. (OCOK Network Management Operations Manual Rev. 7-1-2025 §6.11 / §6 Client Rights, pp.173, 224–226)

SSCC-OCOK — addition end

7. ADVERSE REACTIONS AND SIDE EFFECTS

8. PSYCHOTROPIC MEDICATION — CONSENT, NOTIFICATION, AND MONITORING

SSCC-OCOK — addition start (provider-specific; remove this block if the OCOK contract ends)

For OCOK-placed children, the Network Provider obtains and files monthly medication monitoring reports/logs in the client record, covering all prescribed and over-the-counter medications administered. Staff/caregivers who serve as medical consenters complete Psychotropic Medication Management training pre-service and annually, and medication-administration training is refreshed at least every two years. (OCOK Network Management Operations Manual Rev. 7-1-2025 §6.11, p.173; training pp.264–267)

Implementation guidance: the monthly monitoring log is generated from the Pulse Medication Administration Record (MAR) view / API export (all administered prescription and OTC medications for the month) and filed in the OCOK child's record. A recurring monthly cadence reminder in Pulse assigns the designated owner responsible for producing and filing each child's monthly snapshot, so the obligation is tracked rather than relying on memory. This mechanism is being built into Pulse.

SSCC-OCOK — addition end

SSCC-BELONG — addition start (provider-specific; remove this block if the Belong contract ends)

For a Belong-placed child/youth: a child does not start a new psychotropic medication or a dosage increase without Belong's consent; medication refusals are discussed with the prescribing physician; and the medical consenter may attend prescribing/medication-review appointments in person or virtually if the physician offers. The signed Form 4526 is provided to the Belong Permanency/Adoption Specialist within 4 business days (Belong's timeframe; Refuge House applies the stricter 3 business days used by 2INgage/EMPOWER/SFCS). Belong notifies the child's parents of an initial psychotropic prescription or dosage change at the first scheduled parent meeting. (Belong Stage I & II Provider Manual, Aug 2025, pp.24–25)

SSCC-BELONG — addition end

9. SELF-MEDICATION PROGRAM

10. STORAGE, SECURITY, AND DESTRUCTION

11. APPOINTMENT DOCUMENTATION (DFPS Form 2403)

12. COMPLIANCE MONITORING AND CQI (Pulse Medication Dashboard)

13. DOCUMENTATION AND QUALITY ASSURANCE

14. MEDICAL CONSENTER TRAINING PIPELINE AND PSYCHOTROPIC THERAPY PAIRING (DFPS 24-Hr RCC FY26)

Operationalizes FC-MED-01 Policy Statements 14 and 15.

14.1 Caregiver/Employee Medical Consenters — Form 2759 and Form 2085-B

14.2 Child as Medical Consenter (Ages 16–17)

14.3 Consenter Information to Behavioral Health Clinicians (RCC §5320)

14.4 Psychotropic Therapy-Pairing Verification (RCC §5400 — universal)

Implementation guidance: the Form 2759 annual-renewal anniversary, the per-placement 2759 submission, the 7-day/5-day child-consenter clocks, the 3-business-day §5320 transmission, and the monthly §5400 therapy-pairing check are tracked through case-management cadence reminders; a consenter-training tracker view (2759 currency per consenter, per-child submission log) is planned for Pulse. Until automated, the Case Manager tracks these dates at placement and at the monthly log review, and Compliance & CQI samples them in the Section 12 CQI cycle.

SYSTEM REFERENCE (for auditors and staff)

This section consolidates the implementation so a single document can be provided as evidence of the medication-documentation control environment.

• Staff entry point (Pulse): Medication Dashboard — https://pulse.refugehouse.org/admin-medication-dashboard.html (Azure-authenticated, HIPAA-compliant; staff only).
• Compliance view (Pulse): https://pulse.refugehouse.org/admin/medications/compliance — documents how documentation requirements are met.
• Reminder/escalation service: jduarte-refugehouse/refugehouse-checkin — two scheduled jobs (9:00 PM CT same-day reminder; 7:30 AM CT next-day escalation), a configured overdue threshold (currently 20 hours) that escalates before the 24-hour deadline, exception-token generation near expiry, and a staff "log-on-behalf" path with audit trail.
• Data model (Pulse): MedicationTokens (one per child/time-slot/day, with used/unused state and PRN flag), MedicationLogs (given/refused/missed, administration time, administrant, on-behalf flag), MedicationOnBehalfLogs (audit trail), SyncChildMedications (Radius medication sync), SyncActiveHomes (home/case-manager routing).
• Delivery: email via the configured provider; SMS via the configured messaging integration. Recipient roles: Foster Parent (TO, SMS), Case Manager (TO/CC, email), Program Director (CC on next-day escalation).

Documentation integrity controls (as stated on the Pulse /admin/medications/compliance view):

• Dual timestamps — the system records both the actual administration time and the log-submission time, supporting the 24-hour documentation window. (26 TAC §749.1541(b))
• Immutable logs with audited correction — once created, a medication log cannot be deleted; it can only be corrected through a data-correction process that retains the original and corrected values (version control / audit trail), preserving record integrity. (26 TAC §749.1545)
• Database constraints and validation enforce data integrity at entry.
• Reporting and export — a Medication Administration Record (MAR) view satisfies the cumulative-record requirement, an individual-log view details each administration event, and API access supports export and integration with state systems. (26 TAC §749.1541; §749.1543)
• Electronic signatures — Administration is signed electronically; the "I, [Name], administered…" attestation plus the token-linked audit trail (TokenID → MedicationLogs, AdministeredByPersonGUID, SubmittedDate) satisfies the "name and signature" element of the medication record. (26 TAC §749.534; §749.1541(c)(6))
• Record currency — Each administration is documented within 24 hours — stricter than the general 30-day documentation standard — and foster-parent copies are submitted within 15 days of each month's end. (26 TAC §749.1541(b); §749.535)
• System safeguards — the daily token-generation routine is monitored, with administrator notifications summarizing tokens created and children/time-slots processed, and automatic missing-time-slot alerts so no scheduled dose is left without a log opportunity.

REGULATORY REFERENCES:

• 26 TAC §749.1461, §749.1463, §749.1469 — administering medication (consent, prescription, non-prescription/supplements)
• 26 TAC §749.1501, §749.1503 — self-medication program
• 26 TAC §749.1521 — storage and destruction
• 26 TAC §749.1541, §749.1543, §749.1545 — medication records (24-hour update; required elements; location and retention). Refuge House maintains copies of all of the child's medication records for at least the length of time it provides services to the child; foster parents keep the current month's records at the home and submit copies monthly. (26 TAC §749.1543(a)–(c))
• 26 TAC §749.1561, §749.1563, §749.1565 — medication errors and label errors
• 26 TAC §749.1581, §749.1583 — adverse reactions and side effects
• 26 TAC §749.1603, §749.1605, §749.1607, §749.1609, §749.1611 — psychotropic medication
• DFPS 24-Hour RCC Contract; Texas Provider Gateway; applicable SSCC Provider Manuals (see review.basis)
• DFPS 24-Hour RCC Requirements (FY26): §1560 (medical consent; Form 2085-B representative co-signature); §1561 (Form 2759 per placement/designation; initial + annual training); §1562 (child-as-consenter informed-consent training; Form 2759 within 5 days); §5320 (consenter information to Behavioral Health clinicians within 3 business days of placement); §5400 (psychosocial therapies paired with psychotropic medication; 90-day prescriber visits); §5440 (child-as-consenter psychotropic training within 7 days; documentation within 5 days)
• DFPS Psychotropic Medication Utilization Parameters and Guidelines; Texas Family Code Chapter 266

SSCC alignment (FY-26): Verified 2026-06-19 against the converted SSCC provider manuals (regulatory-references/SSCC/…). 2INgage, EMPOWER, SFCS — psychotropic notification (next business day), Form 4526 within 3 business days, in-person consenter attendance, and the 90-day prescriber review are reflected in §8; aligned. OCOK and Belong carry medication provisions beyond Minimum Standards, captured in the inline SSCC-OCOK and SSCC-BELONG blocks above (OCOK: monthly medication-monitoring logs and medication-error/missed-dose Serious Incident Reporting; Belong: pre-consent for any new/increased psychotropic, the 4-business-day Form 4526 timeframe, and refusal discussion). 4Kids — medication content is DFPS nurse-consultant / PMUR support, not a provider-specific obligation; Minimum Standards govern. Cross-reference: FC-CQI-01; FY-26 SSCC variance matrix.

FORMS/ATTACHMENTS:

• Cumulative Medication Record / Medication Administration Record (Pulse)
• Medication Error Form
• DFPS Form 4526 — Psychotropic Medication Treatment Consent
• DFPS Form 2403 — Medical/Dental/Vision/Hearing/Behavioral-Health Appointment Form
• DFPS Form 2759 — Acknowledgement and Certificate of Completion of Medical Consent Training (DFPS 24-Hr RCC §§1561, 1562)
• DFPS Form 2085-B — Designation of Medical Consenter (DFPS 24-Hr RCC §1560)
• ISP Addendum (medication change)
• Information and Consent Form (caregiver)

FC-MED-01.1 operationalizes FC-MED-01. Procedures may be updated by the Executive Director to reflect regulatory, technological, or operational change without Board approval, provided alignment with the policy's intent is maintained. The reminder/escalation mechanics summarized here are maintained in the refugehouse-checkin repository, which is the source of truth.