6 CCR 1011-1 Chapter 22, pt. 13 - [Effective 3/17/2025] PHARMACEUTICAL SERVICES

13.1 The facility shall maintain an inventory of medications and intravenous fluids sufficient to care for the pregnant/birthing clients and newborns registered for care.
13.2 The facility shall have and follow policies and procedures for the storage, dispensing, and administration, and disposal of medications and intravenous fluids, as developed by the clinical director at Part 5.2(D) and approved by the governing body in accordance with part 3.4(B). Such policies and procedures shall:
(A) Comply with professional standards of practice and applicable state and federal laws and regulations, including but not limited to, 21 CFR Section 1300, et seq., pertaining to federal drug enforcement administration requirements for controlled substances.
(B) Require that medications and intravenous fluids be administered only by a clinical provider or auxiliary or contracted staff member with such administration included in their clinical privileges.
(C) Include procedures for monitoring the expiration date of all medications.
(D) Ensure medications and intravenous fluids maintained in the facility are appropriately stored and safeguarded against diversion or access by unauthorized persons.
(E) Require all medications and intravenous fluids be disposed of in accordance with federal and state laws and regulations and that appropriate records be kept regarding the disposal.
(F) Include the following requirements regarding controlled substances:
(1) Controlled substances shall be maintained in double-locked, secured cabinets. There shall be a written procedure for maintaining accountability and monitoring for diversion.
(2) On-site destruction of controlled substances shall be witnessed and documented in writing by two clinical providers and destroyed in a manner that renders the controlled substances totally irretrievable.

Notes

6 CCR 1011-1 Chapter 22, pt. 13
48 CR 04, February 25, 2025, effective 3/17/2025

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