Utah Admin. Code 432-152-19

Current through Bulletin 2024-23, December 1, 2024

Section R432-152-19 - Pharmacy Services

(1)

(a) The licensee shall provide routine and emergency medications and biologicals.

(b) The licensee may obtain medications and biologicals from community or contract pharmacists, or the licensee may maintain a licensed pharmacy.

(c) The licensee shall ensure pharmacy services are under the direction and responsibility of a qualified, licensed pharmacist who may be employed full time by the facility or may be retained by contract.

(d) The pharmacist shall develop pharmacy service policies and procedures in conjunction with the administrator that address:

(i) medication orders;

(ii) labeling;

(iii) storage;

(iv) emergency medication supply;

(v) administration of medications;

(vi) pharmacy supplies; and

(vii) automatic-stop orders.

(2)

(a) The pharmacist, with input from the interdisciplinary team, shall review the medication regimen of each client at least quarterly.

(b) The pharmacist shall report any irregularities or errors in a client's medication regimen to the prescribing physician and interdisciplinary team.

(c) The pharmacist shall develop and review a record of each client's medication regimen.

(3) The licensee shall maintain an individual medication administration record for each client.

(4) The pharmacist shall participate in the development, implementation, and review of each client's individual program plan, either in person or through a written report to the interdisciplinary team.

(5) The licensee shall ensure the facility has an organized system for medication administration that identifies each medication up to the point of administration and ensure that medications and treatments:

(a) are administered in compliance with the physician's orders;

(b) are administered without error; and

(c) are administered by licensed medical or licensed nursing personnel.

(6)

(a) The licensee shall teach clients how to administer their own medications if the interdisciplinary team determines that self-administration of medications is an appropriate objective.

(b) The licensee shall inform the client's physician of the interdisciplinary team's recommendation that self-administration of medications is an objective for the client.

(c) The licensee may not allow a client to self-administer medications until they demonstrate the competency to do so.

(7) The licensee shall immediately record each telephone order for medications including the date and time of the order and the receiver's signature and title and ensure the person who prescribed the order countersigns and dates the order within 15 days of writing the order.

(8)

(a) The licensee shall maintain records of the receipt and disposition of controlled medications.

(b) The licensee shall maintain records of schedule III and IV drugs in such a manner that the receipt and disposition are readily traced.

(c) The licensee shall, on a sample basis, periodically reconcile the receipt and disposition of controlled drugs in schedules II through I V, drugs subject to the Comprehensive Drug Abuse Prevention and Control Act of 1970 as implemented by 42 CFR Part 308.

(9) The licensee shall:

(a) store medications under proper conditions of sanitation, temperature, light, humidity and security;

(b) secure controlled substances in a manner consistent with applicable pharmacy laws;

(c) separate and secure the storage of non-medication items such as poisonous and caustic materials;

(d) clearly label medication containers;

(e) only allow a person authorized by facility policy top access to medications;

(f) store medication intended for internal use separately from medication intended for external use;

(g) maintain medications stored at room temperature between 59 and 80 degrees Fahrenheit and maintain refrigerated medications between 36 and 46 degrees Fahrenheit;

(h) store medications, and similar items that require refrigeration, securely and segregated from food items; and

(i) store medications in the original pharmacy container and not transfer the medications to other containers;

(j) ensure medications taken out of the facility for home visits, workshops, school or other activities are packaged and labeled by a person authorized to package medications in accordance with law; and

(k) ensure clients who have been trained to self-administer medications in accordance with Subsection R432-152-19(6) have access to keys to their individual medication supply.

(10) The licensee shall ensure labeling of medications and biologicals:

(a) is based on currently accepted professional principles and practices; and

(b) includes the appropriate accessory and cautionary instructions, as well as the expiration date, if applicable.

(11) The licensee shall remove outdated medications and medication containers with worn, illegible or missing labels from use.

(12) The licensee shall immediately remove medications and biologicals packaged in containers designated for a particular client from the client's current medication supply if the medication is discontinued by the physician.

(13) The licensee may send medications with the client upon discharge if ordered by the discharging physician, as long as the medications are released in compliance with Utah pharmacy law and rules and a record of the medications sent with the client is documented in the client's health record.

(14)

(a) Within one month of a medication being discontinued, the licensee shall destroy the individual client medications supplied by prescription or those that remain in the facility after discharge or death of the client as follows:

(b) the licensee shall destroy medications in the presence of the staff pharmacist or consulting pharmacist and an appointed licensed nurse employed by the facility;

(c) if one or both of the individuals listed in Subsection R432-152-19(14)(a) are not available within the month, a licensed nurse and an individual appointed by the administrator may serve as witnesses;

(d) the licensee shall rotate appointments periodically among responsible staff members; and

(e) the licensee shall document and retain the following in the client record for three years:

(i) the name of the client;

(ii) the name and strength of the medication;

(iii) the prescription number;

(iv) the amount destroyed;

(v) the method of destruction;

(vi) the date of destruction; and

(vii) the signatures of the witnesses.

(15) Unless otherwise prohibited by federal or state law, the licensee may return individual client medications to the issuing pharmacy in sealed containers, if unopened, as long as:

(a) no controlled medications are returned;

(b) medications are identified by lot or control number; and

(c) the signatures of the receiving pharmacist and a licensed nurse employed by the licensee are recorded and retained for at least three years in a separate log that lists:

(i) the name of the client;

(ii) the name, strength and prescription number, if applicable;

(iii) the amount of the medication returned; and

(iv) the date of return.

(16)

(a) The licensee shall maintain an emergency medication supply appropriate to the needs of the clients served.

(b) The pharmacist, in coordination with the administrator, shall develop an emergency medication supply policy that ensures:

(i) there is a list of each specific medication and dosage to be included in the emergency medication supply;

(ii) a requirement that containers are sealed to prevent unauthorized use;

(iii) the contents of the emergency medication supply are listed on the outside of the container and the use of contents is documented by nursing staff;

(iv) the emergency medication supply is accessible to nursing staff;

(v) the pharmacist inventories the emergency medication supply monthly; and

(vi) staff replace used or outdated items within 72 hours.

(17) The licensee shall ensure the pharmacy provides medications and biologicals as follows:

(a) medications ordered for administration as soon as possible shall be available and administered within two hours of a physician's order;

(b) antibiotics are available and administered within four hours of a physician's order;

(c) new medication orders are initiated within 24 hours of the order or as indicated by the physician;

(d) prescription medications shall be refilled in a timely manner;

(e) orders for controlled substances are sent to the pharmacy within 48 hours of the order; and

(f) an order sent to the pharmacy may be a written prescription by the prescriber, a direct copy of the original order, or an electronic reproduction.

Utah Admin. Code R432-152-19

Amended by Utah State Bulletin Number 2022-04, effective 1/31/2022

Adopted by Utah State Bulletin Number 2024-01, effective 12/19/2023