DHDTC DAL 18-01: Guidance Concerning the Self-Administration of Medical Marijuana (MM) in General Hospitals

May 9, 2018

DHDTC DAL 18-01: Guidance Concerning the Self-Administration of Medical Marijuana (MM) in General Hospitals

Dear Chief Executive Officer:

This letter provides guidance concerning the self-administration of medical marijuana (MM) in general hospitals. Amendments made to Part 405.5(c) of Title 10 of the New York Code of Rules and Regulations (NYCRR) (effective May 17, 2017) update state requirements concerning the self-administration of medications. It also was amended to be consistent with Title V-A of Article 33 of the New York State Public Health Law (PHL) concerning the medical use of marijuana. As a result of these amendments hospitals may, if they so choose, authorize patients to self-administer medications, including medical marijuana products.

The amendment to Title 10 NYCRR Part 405.5(c) modifies the requirements concerning the administration of all drugs and biologicals to allow for the patient or the patient’s caregiver to self-administer medications. The term “caregiver” includes, but is not limited to, a “caregiver” pursuant to PHL Section 2994-ii(3) and a “designated caregiver” pursuant to PHL Section 3360(5). The new regulation applies to hospital-issued prescription and non-prescription medications and medications brought in by patients (including medical marijuana as defined in PHL Section 3360(8)).

The regulation requires that:

  • The hospital develops policies and procedures which outline how, if at all, self-administration is permitted;
  • There is a medical order for the self-administration;
  • The patient or the patient’s caregiver capacity to self-administer has been assessed;
  • The patient or the patient’s caregiver has been given instructions for the safe and accurate administration of the medication;
  • The security of the medication has been addressed; and
  • Documentation of self-administration is made in the patient’s medical record, as reported by the patient or their caregiver.

For medications brought in by patients, the regulations further require that:

  • The medication is identified and evaluated for integrity;
  • If the patient dies in the hospital, any unused prescription medication is destroyed or disposed of in accordance with all applicable state and federal laws/regulations and the medication is not turned over to the caregiver; and
  • In the case of MM, if the patient dies, the patient’s MM may be turned over to the deceased patient’s designated caregiver, as defined in PHL Section 3360(5) or to appropriate law enforcement for destruction or disposal.

The following Frequently Asked Questions (FAQs) contain guidance specific to MM. A sample MM identification card is also attached.

If you have general questions concerning self-administration of medications, please contact the Division of Hospitals and Diagnostic & Treatment Centers at 518-402-1004. If you have questions specifically concerning MM, please contact the Medical Marijuana Program at 866-811-7957.

Sincerely,

Joshua S. Vinciguerra
Director
Bureau of Narcotic Enforcement

Ruth Leslie
Director
Division of Hospitals and Diagnostic & Treatment Centers

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