December 13, 2012

Question: We had a question raised about whether CMS requires our hospital to allow patients to self-administer their drugs when they are in our facility.  Is this a CMS requirement?

Answer:  No.  The CMS rules on self-administration are permissive, meaning each hospital has a policy decision to make in regards to this practice.

The revised Medicare Conditions of Participation (“CoPs”) that went into effect on July 16, 2012, added self-administration language into the regulations and allows hospitals to have policies and procedures which will permit patients, and their caregivers, to self-administer medications, so long as certain conditions are met.  (Prior to these revisions, the only reference to the self-administration of drugs was in the Interpretive Guidelines to the CoPs addressing the storage and security of meds.)  CMS endorsed the practice of allowing self-administration of medications based on data that indicates that self-administration programs have been shown to lead to great patient satisfaction, shorten lengths of stay, fewer medication errors and ultimately fewer readmissions related to medication problems.  However, to be clear, even under the revised CoPs, there is still no requirement for hospitals to allow self-medication.

If self-medication is allowed at the hospital, keep in mind that accreditation bodies may have their own standards to ensure that medications are safely and accurately administered.  For example, if your facility is accredited by the Joint Commission, we recommend that your hospital incorporate the general requirements found in Standard MM.06.01.01 (e.g., visual inspection), as well as the factors discussed in the revised CoPs (e.g., a determination by a practitioner caring for the patient that the patient, or patient’s caregiver, is capable of safely and accurately administering the meds) into your policy and procedures.