Utah Admin. Code R432-500-18 - Pharmacy Service

(1) The licensee shall ensure that pharmacy space and equipment required are adequate based upon the type of drug distribution system used, number of patients served, and extent of shared or purchased services.

(2) The licensee shall ensure there is a pharmacy supply under the direction of a pharmacist.

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

(4) The licensee shall ensure there are written policies and procedures approved by the medical director and pharmacist that govern the acquisition, storage, and disposal of medications.

(5) The licensee shall ensure the quality and appropriateness of medication usage is monitored by the quality assurance committee.

(6) The licensee shall supply necessary drugs and biologicals in a prompt and timely manner.

(7) The licensee shall ensure a current pharmacy reference manual is available to each staff member.

(8) The licensee shall ensure any medications, solutions, and prescription items are kept secure and separate from non-medicine items in a conveniently located storage area.

(9) The licensee shall ensure an accessible emergency drug supply is maintained in the facility if the facility does not have a pharmacy.

(a) The medical director and the facility pharmacist shall approve the emergency drug supply.

(b) The licensee shall ensure contents of the emergency drug supply are listed on the outside of the container and an inventory of the contents is documented by nursing staff after each use and at least weekly.

(c) The licensee shall replace used items within 48 hours.

(10) The licensee shall maintain medications that are stored at room temperature, within 59 to 80 degrees Fahrenheit (F) or 15 to 30 degrees Celsius (C). The licensee shall maintain refrigerated medications within 36 to 46 degrees F or two to eight degrees C.

(11) The licensee shall securely store medications and other items that require refrigeration separately from food items.

(12) The licensee shall only allow access to drugs by licensed nursing, pharmacy, and medical personnel as designated by facility policy. The licensee shall maintain Schedule II drugs under double-lock and separate from other medication.

(a) The licensee shall maintain separate records of drug use on each Schedule II drug, and ensure the following:

(i) records are accurate and complete including patient name, drug name, strength, administration documentation, and name, title, and signature of person administering the drug;

(ii) the record is reconciled at least daily and retained for at least one year; and

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

(13) The licensee shall maintain records of Schedule III and IV drugs, as identified in the Controlled Substance Act of 1970, 21 USC 802-6, in such a manner that the receipt and disposition of the drugs can be readily traced.

(14) The licensee shall promptly destroy any 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. A licensed physician and a licensed registered nurse, designated by the licensee, shall witness and document the drug destruction.

(15) The licensee shall keep individual drug destruction logs for three years that include the following:

(a) name of the patient;

(b) name and strength of the drug;

(c) prescription number;

(d) amount destroyed;

(e) method of destruction;

(f) date of destruction; and

(g) the signatures of the witnesses.

(16) The discharging physician may order that a single dose or pre-packaged medications may be sent with the patient upon discharge.

(17) The licensee shall ensure the use of multiple dose medications is released in compliance with Utah pharmacy law.

(18) The licensee shall document any medications used in the patient's medical record.

Notes

Utah Admin. Code R432-500-18

Amended by Utah State Bulletin Number 2023-17, effective 8/10/2023