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          44:79:07:01.  Policies and procedures. Each hospice shall establish and practice methods and procedures for medication control that include the following:


          (1)  A requirement that each patient's prescribing physician provide to the facility electronic or written signed orders for any medications taken by the patient; authorization for medications or drugs kept on the person or in the room of the patient; and release of medications;


          (2)  Provisions for proper storage of prescribed medications so that the medications are inaccessible to patients or visitors with requirements for:


               (a)  Separate storage of poisons, topical medications, and oral medications; and

               (b)  A medication prescribed for one patient not to be administered to any other patient;


          (3)  Self-administration of medications to be accomplished with the supervision of a designated employee of the facility to include:


               (a)  A description of the responsibilities of the patient, the patient's family members, and the facility staff; and

               (b)  The provision of written educational material explaining to the patient and the patient's family the patient's rights and responsibilities associated with self-administration; and


          (4)  The proper disposition of medicines that are discontinued because of the discharge or death of the patient, because the drug is outdated, or because the prescription is no longer appropriate to the care of the patient.


          Methods and written policies and procedures shall be established to include the manner of issuance, proper storage, control, accountability, and administration of medications or drugs in accordance with pharmaceutical and nursing practices as well as professional standards.


          The facility and pharmacist shall establish a system of records of receipt and disposition for all controlled drugs in sufficient detail to enable an accurate reconciliation. The facility and pharmacist shall ensure the drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. The facility and pharmacist shall have policies and procedure for the periodic reconciliation of all controlled substances. The policies and procedure shall minimize the time between the actual loss or diversion and the time of detection and follow-up to determine the extent of the loss.


          If a loss or diversion of controlled substances is identified the facility and pharmacist shall evaluate the patients potentially affected consistent with their comprehensive assessment and plan of care. If the systems have not been effective in preventing the loss or diversion of controlled substances, the facility and pharmacist shall review and revise related controls and procedures as necessary.


          Source: 42 SDR 51, effective October 13, 2015.

          General Authority: SDCL 34-12-13.

          Law Implemented: SDCL 34-12-13.


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