R432-500-19. Pharmacy Service

Pharmacy space and equipment required depends upon the type of drug distribution system used, number of patients served, and extent of shared or purchased services.

(1) Direction.

(a) There shall be a pharmacy supply under the direction of a pharmacist.

(b) If the facility does not have a staff pharmacist, it shall retain a consultant pharmacist by written contract.

(c) There shall be written policies and procedures to govern the acquisition, storage, and disposal of medications.

(d) The medical director and facility pharmacist shall approve these policies.

(e) The quality and appropriateness of medication usage shall be monitored by the Quality Assurance Committee.

(2) Pharmacy Supply.

(a) Provision will be made to supply necessary drugs and biologicals in a prompt and timely manner.

(b) A current pharmacy reference manual shall be available to all staff.

(3) Storage.

(a) All medications, solutions, and prescription items shall be kept secure and separate from non-medicine items in a conveniently located storage area.

(b) An accessible emergency drug supply shall be maintained in the facility if the facility does not have a pharmacy.

(i) The emergency drug supply shall be approved by the medical director and the facility pharmacist.

(ii) Contents of the emergency drug supply shall be listed on the outside of the container. An inventory of the contents shall be documented by nursing staff after each use and at least weekly.

(iii) Used items shall be replaced within 48 hours.

(c) Medications stored at room temperature shall be maintained within 59 - 80 degrees F. (15 to 30 degrees C.). Refrigerated medications shall be maintained within 36 - 46 degrees F. (2 to 8 degrees C.).

(d) Medications and other items that require refrigeration shall be stored securely and separately from food items.

(4) Controlled Drugs.

(a) Drugs shall be accessible only to licensed nursing, pharmacy, and medical personnel as designated by facility policy. Schedule II drugs shall be kept under double-lock and separate from other medication.

(b) Separate records of drug use shall be maintained on each Schedule II drug.

(i) Records shall be accurate and complete including patient name; drug name; strength; administration documentation; and name, title, and signature of person administering the drug.

(ii) The record shall be reconciled at least daily and retained for at least one year.

(iii) If medications are supplied as part of a unit-dose medication system, separate records are not required.

(c) Records of Schedule III and IV Drugs shall be maintained in such a manner that the receipt and disposition of the drugs can be readily traced.

(5) Disposal of Drugs.

(a) All discontinued and outdated drugs, including those listed in Schedules II, III or IV of the "Federal Comprehensive Drug Abuse Prevention and Control Act of 1970," shall be destroyed promptly by the facility. The destruction shall be witnessed and documented by two licensed members of the facility staff, preferably a physician and a registered nurse designated by the facility.

(b) The name of the patient, the name and strength of the drug, the prescription number, the amount destroyed, the method of destruction, the date of destruction and the signatures of the witnesses shall be recorded in a separate log kept for this purpose. The log shall be retained for at least three years.

(6) Administration.

(a) A single dose or pre-packaged medications may be sent with the patient upon discharge, when ordered by the discharging physician.

(b) Use of multiple dose medications shall be released in compliance with Utah pharmacy law.

(c) All medications used shall be documented in the patient's medical record.