Section Ph 2301.03 - Practice Standards(a) An institutional permit shall permit the pharmacy to dispense medications to the following, but is not limited to: (1) In-patients of the institution; (2) Staff or employees and their dependents, of the institution;(3) Interim supplies of medication to outpatients in emergency situations;(4) Home infusion therapy to registered outpatients not requiring hospitalization; and(5) Registered outpatients receiving treatment in a hospital-based clinic.(b) If a pharmacist is on the premises, outpatient prescription services may be provided by the pharmacy, on a one-time, no-refill basis, to an ambulatory care patient and any patient who is being discharged with medications related to the patient's hospitalization. Labeling for all outpatient prescriptions shall be according to RSA 318:47-a and RSA 318-B: 11.(c) Members of the board and their agents shall inspect the pharmacy, drug room, or medication room and all areas or departments of the institution where drugs are stored, manufactured, compounded, dispensed, or distributed to ensure: (1) That adequate drug security and storage requirements are met;(2) That proper records are maintained; and(3) That the institution is in compliance with all state and federal drug and pharmacy laws and rules.(d) Those institutions obtaining prescription drugs only on individual prescriptions for specific patients from an off-premise licensed pharmacy shall not be exempt from inspection. (e) Each institution shall have a pharmacy and therapeutics committee or a comparable committee of its medical staff. This committee shall be composed of representatives of the medical staff and the pharmacist-in-charge or a licensed staff pharmacist designated by the pharmacist-in-charge, and representatives of the administrative and nursing departments. The pharmacy representative shall be a voting member of the committee, and the committee shall meet at least twice a year. The functions of this committee shall be to establish the written policies and procedures governing medication management, use of drugs, drug specifications, and drug distribution.(f) The institutional pharmacy shall develop and implement clinical pharmacy practice policies and procedures which provide optimum comprehensive medication management for patients.(g) An institutional pharmacy shall have the ability to dispense a generic or therapeutic equivalent or bio-similar, in accordance with RSA 318:47dd, that has been approved by the pharmacy and therapeutics committee or its equivalent per Ph 2301.03(a).(h) Pharmacists shall have the ability to initiate or modify drug therapy by approved protocol according to the institution policy. Drug therapy initiated or modified by protocol shall be documented in the medical record in accordance with the institutional policy(i) Written policies and procedures shall be adopted which establish the method utilized in the procurement, storage, preparation, and dispending of drugs in all areas or departments of the institution and shall be consistent with state and federal pharmacy laws and rules.(j) Medication orders shall be reviewed by a pharmacist before the medication is initially dispensed or medication orders shall be reviewed by a pharmacist within 24 hours except when: (1) A licensed independent practitioner controls the ordering, preparation, and administration of medications;(3) When a pharmacist is temporarily unavailable;(4) By auto-verification by policy;(5) Those that are for distribution of drugs for floor stock; or(6) When distributed by the ADC.(k) The review of medication orders may include, but shall not limited to the following: (1) Over-utilization or under-utilization; (2) Therapeutic duplication; (3) Drug-disease contraindication; (4) Drug-drug interactions; (5) Incorrect drug dosage or duration of drug treatment;(6) Drug-allergy interactions; and(7) Clinical abuse or misuse.(l) Upon recognizing a clinical problem, the pharmacist shall take steps to avoid or correct the problem.N.H. Admin. Code § Ph 2301.03
Derived from Volume XLII Number 6, Filed February 10, 2022, Proposed by #13323, Effective 1/5/2022, Expires 1/5/2032