Page 77 - Guardian Hospice Care
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           Time In/Out  AM/PM  AM/PM
  Patient Name: MR# Date:  Location of Patient: 
Controlled Substance Disposal Record
In an effort to protect against the inherent dangers presented by the potential diversion of unused controlled substances, effective August 1, 2018, the Louisiana Department of Health expects all licensed hospice providers to be in compliance with LSA R.S.40:219. Therefore, upon the death of a patient receiving hospice services, ownership of the patient’s unused schedule II, Ill, IV, or V controlled substances under 21 C.F.R 1308, may transfer to the hospice for immediate disposal.
I,  associated with Guardian Hospice Care have educated the patient’s family/ representative in proper disposal of controlled drugs. The patient’s family/representative elected to have the hospice nurse assist with disposal of medications by authorized method.
I,  associated with Guardian Hospice Care have left all drugs
at to be destroyed per Nursing Home policy.
   RX#
 Drug/Dosage
 Quantity
  Method of Destruction
                                           Nurse’s Signature  Witness Signature ADDITIONAL INFORMATION:     























































































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