Section R432-750-24 - Pharmaceutical Services(1) The licensee shall establish and implement written policies and procedures to govern the procurement, storage, administration, and disposal of any drugs and biologicals in accordance with federal and state laws.(2) A licensed pharmacist shall supervise pharmaceutical services. The pharmacist's duties shall include the following: (a) advise the hospice and hospice interdisciplinary team on any matters pertaining to the following: (i) procurement, storage, administration, disposal, and record keeping of drugs and biologicals;(ii) interactions of drugs; and(iii) counseling staff on appropriate and new drugs;(b) inspect each drug storage area at least monthly; and(c) conduct patient drug regiment reviews at least monthly or more often if necessary, and make recommendations to physicians and hospice staff.(3) The licensee shall establish and implement written policies and procedures for drug control and accountability. Records of receipt and disposition of each controlled drug shall be maintained for accurate reconciliation.(4) The pharmaceutical service shall ensure that drugs and biologicals are labeled based on currently accepted professional principles, and include the appropriate accessory and cautionary instructions, as well as the expiration date when applicable.(5) The licensee shall provide secure storage for medications. Medications that require refrigeration shall be maintained between 36 and 46 degrees Fahrenheit (F).(6) The licensee shall provide separately locked compartments for storage of controlled drugs as well as other drugs subject to abuse. Only authorized personnel, in accordance with state and federal laws, shall have access to the locked medication compartments.(7) Controlled drugs no longer needed by the patient shall be disposed of by the pharmacist and a registered nurse. The hospice shall maintain written documentation of the disposal.(8) An inpatient hospice licensee shall maintain an emergency drug kit appropriate to the needs of the facility, assembled in consultation with the pharmacist and readily available for use. The pharmacist shall check and restock the kit at least monthly.Utah Admin. Code R432-750-24
Amended by Utah State Bulletin Number 2023-10, effective 5/5/2023