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Controlled Substances in the Home: Management, Accountability and Disposal

Sets out how the Agency manages controlled substances in patients' homes: the written policy given to and discussed with the family when a controlled substance is first ordered, signed acknowledgment in the primary language, prescribing, receipt and reconciliation counts, safe storage, signs of diversion and what to do, and disposal by trained Agency staff after a death or when a drug has expired, with the record federal law requires.

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About this policy
Policy number
CA-HSP-MED-02
Version
1.0
Main rule
22 CCR §74880(d)(4)(F)
Library
California hospice · 60 policies
Category
Clinical tasks
Sections
20

In short

  • When a controlled drug is first ordered, give the family our written instructions, explain them, and get a signature.
  • Count controlled drugs with the family at every registered nurse visit and record the count.
  • Report any count that does not match to the Director of Patient Care Services the same day.
  • Never take a controlled drug out of a patient's home.
  • Only trained licensed staff may dispose of controlled drugs, after a death or when expired, and must record what, how much, when and how.

What's inside

20 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (22 CCR §§74868(c)(17)(C), 74892(r); 42 CFR §418.106(e)(2))
  • 5. When a Controlled Substance Is First Ordered
  • 6. Prescribing and Dispensing
  • 7. Receipt and Reconciliation
  • 8. Storage in the Home
  • 9. Discrepancies and Suspected Diversion
  • 10. Disposal by Agency Staff
  • 11. Disposal by the Patient or Family
  • 12. Inpatient and Facility Settings
  • 13. Responsibilities
  • 14. Records and Compliance Monitoring
  • 15. Staff Training
  • 16. References
  • 17. Related Policies and Forms
  • 18. Approval
  • 19. Revision History

An inspector may ask

  • Show me where you gave this family your written controlled substance policy and discussed it when the first controlled drug was ordered.
  • Show me the signed acknowledgment of the instructions, in the family's language.

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