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Policy and Procedure Manual
Medication Policy
Hospice Decision for Payment
The Hospice Patient Care Coordinator shall make decisions about which medications that hospice is
responsible to pay for and which ones that hospice is not responsible for. The Patient Care Coordinator
may consult the Medical Director for advice if needed. All medications which are directly or indirectly
related to the terminal illness will be the responsibility of hospice for payment. All medications that are
not related, either directly or indirectly, to the terminal illness will be the responsibility of the patient or
other appropriate parties. An example of this would be a cancer patient who has a blood pressure
medication they have been taking for several years.
Dispensing and Administering of Drugs and Biologicals
Agency shall provide oversight of all medications that are prescribed for the patient. For hospice
patients, those medications that are related to the patient’s terminal illness will be the financial
responsibility of the hospice. 24 hour availability of any medications needed due to the patient’s terminal
illness will be provided through contracts hospice has with area pharmacies. Agency staff will also
arrange for the timely delivery of any medications needed, that are related to the patient’s terminal
illness. Non-pharmacological interventions will be offered for treatment of symptoms such as pain,
anxiety, shortness of breath.
The Patient Care Coordinator or primary nurse develops and maintains a drug profile on each patient.
Nursing staff assess the appropriateness of the medications taken by the patient on a regular basis and
document this in the visit report. Individuals administering the medications are specified in the plan of
care. The capabilities of those individuals to administer medications to the patient will be assessed by an
RN on admission.
When Agency staff becomes aware that a patient needs a medication that is determined related to the
terminal illness, assessment will be made by the primary nurse or Patient Care Coordinator of how soon
the patient will need the medication to ensure maximum comfort, relief of symptoms or other factors in
their care. Once a decision has been reached, arrangements will be made for delivery by pharmacy or
Agency staff or family members of patient to meet the time frame decided upon.
At or before the time of the medication arrival, the patient, their caregiver or other appropriate persons
will be instructed by an Agency skilled nurse on the medication regimen, frequency, route, any possible
side effects and any other important facts necessary for care of patient such as medication preparation,
proper sanitation, temperature, lighting, moisture and ventilation, as well as safety, security and storage.
In an appropriate time frame after the medication change a skilled nurse will assess the patient’s
response and notify a supervising RN of any problems that develop.
Ordering, Storage, Administration, Disposal and Recordkeeping
A licensed pharmacist, who under a formal agreement with the Agency will advise Agency staff on
ordering, storage, administration, disposal, and recordkeeping of drugs and biologicals. The primary
nurse will request only an amount of medications necessary, to minimize waste of medications.
Orders for Medication
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A physician will order all medication for the Agency patient, whether it is the Attending Physician or the
Hospice Medical Director, or their designated physician representative.
All verbal orders for any medication will be taken only by an Agency employed licensed nurse,
pharmacist, or another physician. The individual receiving the order must record and sign it immediately
and have the prescribing physician sign it within 14 working days. Orders with variable doses or
frequencies shall specify a maximum dose or frequency and the reason for administration.
Medication Administration
Medications will be administered only by a staff licensed nurse or a physician. The patient, or patient’s
caregiver or other designated family members or friends who have been instructed in medication
administration, frequency, dosage, and possible side effects may administer medication if the patient’s
attending physician approves.
Accuracy of Drug Distribution System
Agency skilled staff will evaluate the accuracy of the drug administration system at all times. If a
medication error or the potential for a medication error is discovered, every effort will be made to
determine the nature of the error and teaching will be done about the medication and its administration
to prevent recurrence of the error. The Administrator and/or supervising RN will be notified immediately
upon discovery of a medication error. The Attending Physician will be notified during that same day of a
regular workday or the next working day, during an after hours discovery of a medication error. In the
event that the patient has suffered an adverse reaction to the medication error, the Attending Physician or
the appropriate on-call physician will be notified immediately.
Control and Accountability
The area pharmacies, which have procedures for control and accountability of all drugs and biologicals
throughout their pharmacy, will be responsible for maintaining the security of these medications while
on their premises. All drugs will be dispensed in compliance with Federal and State laws. A record will
be maintained of receipt and disposition of all controlled drugs to enable an accurate reconciliation.
Upon the delivery of a controlled substance medication, the staff nurse counts each unit of medication in
the presence of one other person, usually a family member of the patient. This person then initials the
visit report to verify that the correct amount of the controlled substance was delivered to the patient. The
staff nurse also initials the visit report to verify the delivery and accuracy of the count.
The labeling of all drugs and biologicals will be performed by the supplying pharmacist. This will be
done according to currently accepted professional principles and include any appropriate accessory
and/or cautionary instructions, as well as the expiration date when applicable.
Each patient’s individual drug container also contains his/her full name, the prescribing physician’s
name, and the name, strength and quantity of the drug dispensed.
In the event that single unit packaging is used, it will bear the name and strength of the drug and the lot
and control number and be clearly identified with the patient’s full name and the prescribing physician’s
name.
Drug containers with illegible, damaged, incomplete or missing labels will be returned to the pharmacist
for proper labeling.
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In accordance with State and Federal laws, the written prescriptions for controlled substances will be
stored in a locked compartment. Only authorized Agency administrative staff will have access to the
combination to the safe that these items may be stored in. Any controlled substance medications that are
in the possession of Agency skilled staff will be maintained in the package that was sealed by the
pharmacy and prompt delivery will be made of these medications.
When a patient is consistently taking more than the prescribed dosage of their pain medication, an
assessment will be made of their pain management by use of a pain. A medication flow sheet may be
utilized as a tool to evaluate pain management. Their Attending Physician or the Hospice Medical
Director (in the event that the Attending Physician is unavailable) will be consulted for an adjustment of
their pain control regimen.
Any Agency staff member who misuses a controlled substance medication will be subject to disciplinary
action, up to and including dismissal from employment. This will also be reported to the State Board of
Nursing and the proper local legal authorities if this occurs.
The agency skilled nurse will assess for patterns of misuse of controlled substances in the patient’s
home, also. Any suspicious circumstances that are determined will be reported immediately to the
Administrator or other supervising RN. Further investigation will be performed by the skilled nurse and
other appropriate team members. The results of the investigation will be brought to the interdisciplinary
team and the Ethics Team, if appropriate, for intervention.
The Administrator or other supervising RN will also notify the prescribing physician of possible misuse
of controlled substances in the patient’s home as well as any action taken to remedy the situation.
Individual circumstances influence the types of monitoring methods for schedule II narcotics. Different
types of monitoring include:
 Counting medications weekly,
 Daily recording of all dosages given by family members or caregiver,
 Use of breakthrough pain medication administration flow sheet,
 Weekly estimation of frequency of usage of medications, to determine appropriate dosages for
adequate pain management,
 Assessment of pain management control symptomology,
 More frequent visits to monitor pain management and control of pain,
 Other pain management assessment or methodology will be done on an individual basis
according to specific circumstances that occur.
Controlled Substance Medication Discrepancies
In the event that medication discrepancies exist with controlled substances, the Hospice IDT or Patient
Care Coordinator may change patient’s medication management system to a cautionary method, which
may involve, but not be limited to, the following components:
 Review of medications that are controlled substances, the frequency of medication administration,
the possibility of other persons administering these medications but not recording them, etc. Further
teaching will be done if any of these issues may exist.
 Locked protection of controlled substance medication with one key being in the possession of the
primary caregiver and the other key being maintained in a locked location at the Agency office.
 Counts of controlled substances on hand each visit to maintain closer regulation.
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Policy and Procedure Manual
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Notification of Medical Director and Attending Physician of the situation.
Controlled substances will be picked up by Agency staff and a count will be done at the pharmacy in
view of both the staff member and the pharmacist, then counted again at the patient=s home with a
family member witnessing the count. Both of these counts will be recorded and signed on a home
visit page and maintained in the patient chart.
Notification of other authorities as deemed necessary by Administrator or Hospice IDT.
Document the above.
Disposal
Controlled drugs no longer needed by the patient are disposed of by an Agency registered nurse with
another staff member or family member as witness, unless family members refuse to allow disposal. Do
not insist on destroying the meds. It is the property of the family, even though hospice bought it. Be
sure to document the offer. The witness will sign the narcotic disposal record, after the registered nurse
completes the form. This disposal record will include the prescription number of each destroyed
medication as well as the method of destruction. This form will be maintained in the patient=s file at the
Agency. The offer to dispose of the medications will be documented.
Staff Obtaining, Delivery and Storage of Medication
Obtaining Medication - When a nurse becomes aware of a patient’s need for medication for any reason,
this nurse will confer with a physician about the need. The physicians will be chosen in the following
order:
1) Attending physician or physician on call for this physician
2) Medical Director
The physician will either call the pharmacy with the prescription or write a prescription, in the instance
of it being a prescription medication. If it is an over the counter medication, the physician will give the
order to the nurse. The nurse will insure that the written prescription is delivered to the appropriate
pharmacy and protect the prescription from loss by maintaining it in a secure place. The medication will
then be obtained from the pharmacy, either by staff or by the patient’s designated family member or
delivered by the pharmacy personnel if appropriate.
Delivery and Storage - If the medication is obtained by staff, it will be delivered in a timely fashion with
consideration taken for the acuity of need for this medication at a specific time. If the medication is
needed “as soon as possible”, it will be delivered by a staff member of Howard County Home Health and
Hospice. If the medication is not needed until the date of the next scheduled visit, it will be stored at the
Agency office in a central location. If the medication is a narcotic or controlled substance, it will be
stored in a locked location within the Agency until such time as it can be delivered. A daily count of any
controlled substance medication will be done and recorded by two skilled nurses and this count will be
documented and signed by each nurse. When the medication is taken to the patient’s home, it will be
handled in the manner described earlier in this policy. If a medication is stored in the medication
refrigerator, a daily check of the refrigerator temperature will be done and recorded on a log maintained
near the refrigerator to assure maximum effectiveness of the medication. Note - if the medication is
delivered by an employee who is not a nurse, they may only handle closed packages and not inventory or
handle individual dosage units.
Identification of Medication Adverse Effects
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Policy and Procedure Manual
All professional staff, including nursing and therapy staff, will assess patients each visit for the
possibility of adverse effects to medication and report to physician if discovered.
Non-Compliance
If non-compliance with patient medication is discovered, re-education will be done with the patient
and/or their caregiver about the action of that medication and the need for patient to take as prescribed. If
non-compliance persists, the physician will be notified.
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