(a)  The hospice shall establish and implement written policies and procedures to govern the procurement, storage, administration and disposal of all drugs and biologicals in accordance with federal and state laws.

(b)  Pharmaceutical services shall be provided directly or through written agreement under the supervision of a licensed pharmacist and in accordance with Rule .0505 of this Subchapter.  The pharmacist's duties shall include, but are not limited to the following:

(1)           advising the hospice and the hospice interdisciplinary team on all matters pertaining to the procurement, storage, administration, disposal and record‑keeping of drugs and biologicals; interactions of drugs; and counseling staff on appropriate and new drugs;

(2)           inspecting all drug storage areas at least monthly;

(3)           conducting patients' drug regimen reviews frequently enough to monitor symptom control, no less often than monthly, with appropriate recommendations to the physician and hospice staff.

(c)  The hospice shall establish and implement written policies and procedures for drug control and accountability.  Records of receipt and disposition of all controlled drugs shall be maintained for accurate reconciliation.

(d)  Medications shall be labeled as described in the Pharmacy Laws of North Carolina.

(e)  Medications must be stored in locked areas, at proper temperature, and accessible only to authorized persons in accordance with federal and state laws.  Separately locked compartments must be provided for storage of controlled substances listed in the North Carolina Controlled Substances Act and other drugs subject to abuse.

(f)  Controlled substances no longer needed by the patient are to be disposed of in compliance with the North Carolina Controlled Substances Act.

(g)  The hospice shall maintain an emergency drug kit appropriate to the needs of the facility, assembled in consultation with the pharmacist and readily available for use.  The pharmacist shall check and restock the kit as necessary, at least monthly, or more often if needed.


History Note:        Authority G.S. 131E‑202;

Eff. June 1, 1991.