LAC 48:I.9351. Organization and Staffing

A. Pharmaceutical services shall be directed by a registered pharmacist, licensed to practice in Louisiana on either a full-time, part-time or consulting basis. The director of pharmacy shall be responsible for the procurement, storage, dispensing, supervision and management of all legend and non-legend drugs for the hospital, and shall maintain complete and accurate records of all drug transactions by the pharmacy. There shall be an adequate number of personnel to ensure quality services, including emergency services, 24 hours per day, seven days per week. A pharmacist shall be on call after hours, whenever the pharmacy does not provide 24-hour service. B. Hospital pharmacies that are not staffed on a 24-hour basis shall have an adequate security detection device. C. Hospital pharmacies that are not open after regular working hours shall make drugs available for the staff by use of a night drug cabinet, after-hours medication carts, or an automated storage and distribution device. The hospital pharmacy shall maintain an inventory and a list of these drugs, which are approved by the pharmacy director and the appropriate hospital committee. D. Each off-site campus shall have a site specific controlled dangerous substance (CDS) license if they will be dispensing controlled dangerous substances.