Washington Administrative Code › Title 246 - Health, Department of › FACILITY STANDARDS AND LICENSING › Chapter 246-322 - Private psychiatric and alcoholism hospitals › Section 246-322-210 - Pharmacy and medication services

Current through Register Vol. 24-14, July 15, 2024
The licensee shall:
(1) Maintain the pharmacy in the hospital in
				a safe, clean, and sanitary condition;
(2) Provide evidence of current approval of
				pharmacy services by the pharmacy quality assurance commission under chapter
				18.64 RCW;
(3) Develop and
				implement procedures for prescribing, storing, and administering medications
				according to state and federal laws and rules, including:
(a) Assuring professional staff who prescribe
				are authorized to prescribe under chapter 69.41 RCW;
(b) Assuring orders and prescriptions for
				medications administered and self-administered include:
(i) Date and time;
(ii) Type and amount of drug;
(iii) Route of administration;
(iv) Frequency of administration; and
(v) Authentication by professional
				staff;
(c) Administering
				drugs;
(d) Self-administering
				drugs;
(e) Receiving and recording
				or transcribing verbal or telephone drug orders by authorized staff;
(f) Authenticating verbal and telephone
				orders by prescriber in a timely manner, not to exceed forty-eight hours for
				inpatients;
(g) Use of medications
				and drugs owned by the patient but not dispensed by the hospital pharmacy,
				including:
(i) Specific written
				orders;
(ii) Identification and
				administration of drug;
(iii)
				Handling, storage and control;
(iv)
				Disposition; and
(v) Pharmacist and
				physician inspection and approval prior to patient use to ensure proper
				identification, lack of deterioration, and consistency with current medication
				profile;
(h) Maintaining
				drugs in patient care areas of the hospital including:
(i) Hospital pharmacist or consulting
				pharmacist responsibility;
(ii)
				Legible labeling with generic and/or trade name and strength as required by
				federal and state laws;
(iii)
				Access only by staff authorized access under hospital policy;
(iv) Storage under appropriate conditions
				specified by the hospital pharmacist or consulting pharmacist, including
				provisions for:
(A) Storing medicines,
				poisons, and other drugs in a specifically designated, well-illuminated, secure
				space;
(B) Separating internal and
				external stock drugs; and
(C)
				Storing Schedule II drugs in a separate locked drawer, compartment, cabinet, or
				safe;
(i)
				Preparing drugs in designated rooms with ample light, ventilation, sink or
				lavatory, and sufficient work area;
(j) Prohibiting the administration of
				outdated or deteriorated drugs, as indicated by label;
(k) Restricting access to pharmacy stock of
				drugs to:
(i) Legally authorized pharmacy
				staff; and
(ii) Except for Schedule
				II drugs, to a registered nurse designated by the hospital when all of the
				following conditions are met:
(A) The
				pharmacist is absent from the hospital;
(B) Drugs are needed in an emergency, and are
				not available in floor supplies; and
(C) The registered nurse, not the pharmacist,
				is accountable for the registered nurse's
				actions;