1. (1)(a) The pharmacy of a licensee currently accredited and conforming to the standards of the Joint Commission is determined to be in compliance with this section.

   1. (b) If a licensee is not accredited by the Joint Commission, then the licensee's pharmacy services shall comply with the requirements in this section.
2. (2) A licensed pharmacist shall direct the pharmacy department and service.
3. (3) The licensee shall employ personnel in keeping with the size and activity of the department and service.
4. (4) If the licensee uses only a drug room and the size of the hospital does not warrant a full-time pharmacist, a consultant pharmacist may be employed.
5. (5) The pharmacist is responsible for developing, supervising, and coordinating the activities of the pharmacy.
6. (6) The licensee shall provide access to emergency pharmaceutical services.
7. (7) The licensee shall ensure the pharmacist is trained in the specific functions and scope of the hospital pharmacy.

8. (8) The licensee shall provide facilities for the safe storage, preparation, safeguarding, and dispensing of drugs and ensure:

   1. (a) a current toxicology reference, and other references as needed for effective pharmacy operation and professional information, are available;
   2. (b) double-locked storage is provided for any controlled substance and electronically controlled storage of a narcotic is permitted if the hospital uses automated dispensing technology;
   3. (c) any floor-stock is kept in a secure area in the patient care unit;
   4. (d) any room-temperature medication is stored in a room where the temperature is maintained between 59 and 80 degrees Fahrenheit (F); and
   5. (e) any refrigerated medication is stored in a refrigerator where the temperature is maintained between 36 and 46 degrees F.
9. (9) The licensee shall maintain records of the transactions of the pharmacy and medication storage unit and coordinate with other hospital records.

10. (10)(a) In accordance with Section R156-17b-605, the licensee shall:

    1. (i) maintain a recorded and signed floor-stock controlled substance count once per shift; or

       1. (ii) use automated dispensing technology.
    2. (b) A licensee that uses automated dispensing technology shall implement a system for accounting of controlled substances dispensed by the automated dispensing system.
    3. (c) The record shall list the name of the patient receiving the controlled substance, the date, type of substance, dosage, and signature of the person administering the substance.

11. (11)(a) The director of the pharmaceutical department or service shall develop written policies and procedures, in coordination with the medical staff, that pertain to the intra-hospital drug distribution system and the safe administration of drugs.

    1. (b) Medical staff shall administer drugs that are provided to floor units in accordance with hospital policies and procedures.
    2. (c) The medical staff, in coordination with the pharmacist, shall establish standard stop orders for medications not specifically prescribed in regard to time or number of doses.
    3. (d) The pharmacist shall have full responsibility for dispensing of drugs.
    4. (e) The licensee shall ensure there is a policy stating who may have access to the pharmacy or drug room when the pharmacist is not available.
    5. (f) The licensee shall ensure there is a documentation system for the accounting and replacement of drugs, including narcotics, to the emergency department.
    6. (g) The licensee shall ensure medication errors and adverse drug reactions are reported immediately in accordance with written procedures including notification of the practitioner who ordered the drug.

KEY: health care facilities

Date of Last Change: June 5, 2026

Notice of Continuation: August 22, 2025

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203