July 2004

Information Bulletin 04-12
NH-103
SLF-15
HC-20

Discharge/Transfer Of Individuals
With Possession Of Controlled Drugs

Purpose:

This Minnesota Department of Health (MDH) Information Bulletin establishes a standard licensing waiver process from Minnesota Nursing Home Rule 4658.1350 Subpart 1; Supervised Living Facility Rule 4665.4600; and Assisted Living Home Care Provider Rule 4668.0870 Subpart 3A by allowing individuals and/or the responsible party of these individuals who are discharged or transferred to retain possession of their controlled drugs, rather than having the licensee destroy these controlled drugs. The Minnesota Board of Pharmacy concurs with the condition of the waiver outlined in this bulletin. There is not a comparable rule part for Class A Home Care Providers, therefore a waiver is not necessary.

Current licensure provisions require that licensees destroy controlled drugs and thus prohibit individuals/responsible parties from taking their controlled drugs with them when discharged or transferred and have prompted individual waiver requests to MDH. To avoid having to submit an individual waiver request to MDH, a licensee must follow the provisions set forth in this Information Bulletin.

Conditions of the Waiver:

Nursing Home Rule 4658.1350 Subpart 1, Drugs given to discharged residents; SLF Rule 4665.4600, Disposition of Medications; and ALHCP Rule 4668.0870 Subpart 3A, Disposition of Medications are waived under the following conditions:

• Written policies and procedures are established to comply with the provision of this waiver including the provision of ensuring that controlled medications sent with the individuals are sent in child resistant medication containers unless the individual/responsible party requests otherwise.

• Order from a health care practitioner licensed to prescribe in Minnesota authorizing a currently prescribed controlled substance medication to be released upon discharge/transfer.

• If currently prescribed controlled drugs are released to a responsible person, this person who, because of resident/client's incapacity, makes decisions about the individual's care must be identified in the medical record.

• A notation of the controlled drug medication release listing the date, quantity, name, strength, and dosage form of the medication; prescription number, name, address and telephone number of the dispensing pharmacy; name and signature of the person releasing the drug; and name and signature of the person receiving the controlled drug upon discharge.

• Upon death of an individual, controlled drugs MUST NOT be released to the individual's responsible person. Unused portions of controlled drugs after an individual's death must be disposed of by contacting the Minnesota Board of Pharmacy, which shall furnish the necessary instructions and forms, a copy of which shall be kept on file by the licensee for two years.

Waivers of all other Minnesota Rule requirements would need to be submitted in writing to the Minnesota Department of Health.

This waiver provision will remain in effect indefinitely; however, all waivers are subject to review as deemed necessary by the Minnesota Department of Health. Please remember that all alternative measures or conditions attached to a variance or waiver shall have the force and effect of the licensure rule(s) and shall be subject to the issuance of correction orders and penalty assessments in accordance with the provisions of Minnesota Statutes, section 144.653. The period of time for correction and the amount of fines specified for the particular rules for which the variance or waiver was requested, shall apply.

If you have any questions regarding this Information Bulletin, please contact in writing:

Minnesota Department of Health
Health Regulation Division
Licensing and Certification Program
85 East Seventh Place, Suite 300
PO Box 64900, St. Paul, Minnesota 55164-0900
Telephone: (651) 201-4200