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

Universal Citation: WA Admin Code 246-322-210

Current through Register Vol. 24-18, September 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;

(4) The appropriate professional staff committee shall approve all policies and procedures on drugs, after documented consultation with:

(a) The pharmacist or pharmacist consultant directing hospital pharmacy services; and

(b) An advisory group comprised of representatives from the professional staff, hospital administration, and nursing services;

(5) When planning new construction of a pharmacy:

(a) Follow the general design requirements for architectural components, electrical service, lighting, call systems, hardware, interior finishes, heating, plumbing, sewerage, ventilation/air conditioning, and signage in WAC 246-318-540;

(b) Provide housekeeping facilities within or easily accessible to the pharmacy;

(c) Locate pharmacy in a clean, separate, secure room with:
(i) Storage, including locked storage for Schedule II controlled substances;

(ii) All entrances equipped with closers;

(iii) Automatic locking mechanisms on all entrance doors to preclude entrance without a key or combination;

(iv) Perimeter walls of the pharmacy and vault, if used, constructed full height from floor to ceiling;

(v) Security devices or alarm systems for perimeter windows and relites;

(vi) An emergency signal device to signal at a location where twenty-four-hour assistance is available;

(vii) Space for files and clerical functions;

(viii) Break-out area separate from clean areas; and

(ix) Electrical service including emergency power to critical pharmacy areas and equipment;

(d) Provide a general compounding and dispensing unit, room, or area with:
(i) A work counter with impermeable surface;

(ii) A corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter;

(iii) Storage space;

(iv) A refrigeration and freezing unit; and

(v) Space for mobile equipment;

(e) If planning a manufacturing and unit dose packaging area or room, provide with:
(i) Work counter with impermeable surface;

(ii) Corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter; and

(iii) Storage space;

(f) Locate admixture, radiopharmaceuticals, and other sterile compounding room, if planned, in a low traffic, clean area with:
(i) A preparation area;

(ii) A work counter with impermeable surface;

(iii) A corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter;

(iv) Space for mobile equipment;

(v) Storage space;

(vi) A laminar flow hood in admixture area; and

(vii) Shielding and appropriate ventilation according to WAC 246-318-540(3)(m) for storage and preparation of radiopharmaceuticals;

(g) If a satellite pharmacy is planned, comply with the provisions of:
(i) Subsection (5)(a), (5)(c)(i), (ii), (iii), (iv), (v), and (vi) of this section when drugs will be stored;

(ii) Subsection (5)(c)(vii), (viii), and (ix) of this section, if appropriate; and

(iii) Subsections (5)(d) and (f) of this section if planned;

(h) If a separate outpatient pharmacy is planned, comply with the requirements for a satellite pharmacy including:
(i) Easy access;

(ii) A conveniently located toilet meeting accessibility requirements in WAC 51-20-3100; and

(iii) A private counseling area.

Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. 95-22-012, § 246-322-210, filed 10/20/95, effective 11/20/95.

Disclaimer: These regulations may not be the most recent version. Washington may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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