28 Pa. Code § 139.33 – Formula preparation.

(a) A registered professional nurse or dietitian shall be in charge of formula preparation.
(b) Formula shall be individually bottled and sterilized by pressure method 230�DF. for 25 minutes, with the following exceptions:
1. (1) If hermetically sealed commercial formula products are used and the hospital’s method of dispensing the formula has been approved by the Department.
2. (2) Special mixtures which cannot be subjected to terminal heating shall be prepared by aseptic technique.
(c) Each formula bottle shall be labeled with the identity of its contents.
(d) Bacteriologic examinations of the equipment used, and analysis of techniques shall be done at least once each month. Plate counts on random sample of 24-hour milk mixtures shall not exceed 25 organisms per milliliter. Results of the bacteriologic tests shall be recorded and maintained on file.