1. (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. (2)(a) A licensed pharmacist shall supervise pharmaceutical services.

   1. (b) The licensee shall ensure the pharmacist advises the hospice and hospice interdisciplinary team regarding:

      1. (i) counseling staff on appropriate and new drugs;
      2. (ii) interactions of drugs; and
      3. (iii) procurement, storage, administration, disposal, and record-keeping of drugs and biologicals.
   2. (c) The licensee shall ensure the pharmacist conducts patient drug regimen reviews at least monthly, or more often if necessary, and make recommendations to physicians and hospice staff.
   3. (d) The licensee shall ensure the pharmacist inspects each drug storage area at least monthly.

3. (3) The licensee shall:

   1. (a) establish and implement written policies and procedures for drug control and accountability;
   2. (b) maintain receipts and disposition of each controlled drug for accurate reconciliation; and
   3. (c) keep these records for accurate reconciliation.
4. (4) The licensee shall ensure that pharmaceutical service drugs and biologicals are labeled based on currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date when applicable.
5. (5) The licensee shall provide secure storage for medications and ensure medications that require refrigeration are maintained between 36 and 46 degrees Fahrenheit.

6. (6)(a) The licensee shall provide separately locked compartments for the storage of controlled drugs as well as other drugs subject to abuse.

   1. (b) Per state and federal laws, only authorized personnel shall have access to the locked medication compartments.

7. (7)(a) The pharmacist and a registered nurse shall dispose of any controlled drugs no longer needed by the patient.

   1. (b) The licensee shall maintain written documentation of the disposal.

8. (8)(a) A hospice inpatient facility 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.

   1. (b) The pharmacist shall check and restock the emergency drug kit at least monthly.

KEY: health care facilities

Date of Last Change: February 18, 2025

Notice of Continuation: August 13, 2021

Authorizing, and Implemented or Interpreted Law: 26B-2-202; 26B-2-204