Mississippi Administrative Code › Title 30 - Professions and Occupations › Part 3001 - MISSISSIPPI PHARMACY PRACTICE REGULATIONS › Article LI - CONSULTING PHARMACISTS TO AMBULATORY SURGERY CENTERS AND MULTI-PROVIDER CLINICS

Current through June 25, 2024
1. For purposes of
			 this article, a consultant pharmacist for an ambulatory surgery center (ASC) or
			 multi-provider clinic (MPC) shall mean any Mississippi licensed pharmacist who
			 is listed on an ASC/MPC permit (pharmacist-in-charge). The consultant
			 pharmacist is on site at least monthly to conduct a review of medication
			 related processes and to ensure appropriate reconciliation of controlled
			 substances. The consultant pharmacist for an ASC/MPC would not need a nursing
			 home consultant certificate. The consultant pharmacist is responsible for
			 providing recommendations only to the ASC/MPC.
2. Responsibilities of the ASC/MPC Consultant
			 Pharmacist
A. The ASC/MPC Consultant
			 Pharmacist shall be responsible for advising the ASC/MPC on all matters related
			 to safe and efficient administration, control, and accountability for drugs and
			 proper licensing. The responsibilities of the consultant pharmacist shall
			 include developing policies and procedures and implementation for the
			 following:
(1) All medications shall be
			 purchased from facilities registered with the Mississippi Board of
			 Pharmacy
(2) Preparation of sterile
			 medications prepared within the ASC/MPC
(3) Admixture of parenteral
			 products
(4) Compounding of drugs,
			 solutions, ointments, lotions, etc.
(5) To assure that no legend medication shall
			 be stored in patient care areas except upon the approval of the Consultant
			 Pharmacist
(6) Establishment of
			 specifications for procurement of all materials, including drugs, chemicals and
			 biologicals, subject to approval of the appropriate committee of the ASC/MPC
			 and compliance with DSCSA requirements
(7) Participation in the development of a
			 formulary for the ASC/MPC where applicable
(8) Proper filling and labeling of all
			 containers from which drugs are to be administered
(9) Maintenance of records of all
			 transactions of the ASC/MPC as may be required by applicable law, state and
			 federal, and as may be necessary to maintain accurate control and
			 accountability for all pharmaceutical materials
(10) Assure that all drugs shall be stored in
			 areas within the ASC/MPC and satellite storage areas to provide proper
			 sanitation, temperature, light, ventilation, moisture control, segregation and
			 security; that disinfectants and drugs for external use are stored separately
			 and apart from drugs for internal use or ingestion; that outdated or other
			 unusable drugs are identified and stored in a manner that will prevent their
			 administration prior to disposition; that emergency drugs are in adequate and
			 proper supply at designated locations
(11) Assure that all areas occupied by the
			 ASC/MPC shall be capable of being locked to prevent unauthorized access, and
			 that all areas where drugs are stored or administered shall be locked
(12) Ensure that discontinued and outdated
			 drugs are returned to a MS Board of Pharmacy registered reverse distributor or
			 destroyed onsite following DEA rules for onsite destruction and use of DEA Form
			 41.
(13) Drugs shall be
			 administered only upon receipt of a written or oral order. There shall be no
			 "take home" medications dispensed under this permit. Samples are exempt from
			 this Article.
(14) All requirements
			 of the Controlled Substances Act of 1970 and the requirements set forth in the
			 regulations of the Mississippi Board of Pharmacy in the purchasing, storing,
			 administration, record keeping, and disposal of controlled substances are met.
			 There shall be policies and procedures to ensure the control of these drugs at
			 all times, including those instances when drugs are stored in the surgery
			 departments, nursing stations, clinics, diagnostic laboratories, etc. Periodic
			 (at least monthly) inspections by the consultant pharmacist of the proper
			 storage of these drugs is required and deficiencies must be
			 corrected.
(15) At least monthly
			 consultant audits of records of acquisition and disposition. Monthly audits of
			 controlled substance inventory.
(16) Assisting the medical director as
			 applicable in developing inventory listings of drugs to be included in these
			 areas and assure that:
(a) Such drugs are
			 available therein, properly stored and labeled
(b) Only pre-packaged drugs are available
			 therein, in amounts sufficient for immediate therapeutic requirements
(c) Each drug stored in these areas shall be
			 assigned a "par value" and each addition or withdrawal by authorized persons
			 shall be properly documented. The consultant pharmacist shall audit these areas
			 on a regular basis but no less than once per month.
(17) The consultant pharmacist shall provide
			 a monthly report to the ASC/MPC outlining any findings from their review. This
			 document shall be signed by the medical director or designee and
			 dated.
(18) A consultant pharmacist
			 for an ASC/MPC shall report to the appropriate regulatory or licensing agency
			 any serious deficiency or violation noted on his/her consultant report if such
			 deficiency is not corrected or addressed by the permit holder by the date of
			 the next monthly visit by the consultant pharmacist at the permit
			 site.