WAC 246-322-210. Pharmacy and medication services

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rooms with ample light, ventilation, sink or lavatory, and sufficient work area; (j) Prohibiting the administration of outdated or deteriorated drugs, as indicated by label; (k) Restricting access to pharmacy stock of drugs to: (i) Legally authorized pharmacy staff; and (ii) Except for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.