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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 8238 (December 30, 2023).

28 Pa. Code § 211.9. Pharmacy services.

§ 211.9. Pharmacy services.

 (a)  Facility policies shall ensure that:

   (1)  Facility staff involved in the administration of resident care shall be knowledgeable of the policies and procedures regarding pharmacy services including medication administration.

   (2)  [Reserved].

 (b)  Facility policies shall ensure that medications are administered by authorized persons as indicated in §  201.3 (relating to definitions).

 (c)  Medications and biologicals shall be administered by the same licensed person who prepared the dose for administration and shall be given as soon as possible after the dose is prepared.

 (d)  Medications, both prescription and non-prescription, shall be administered under the orders of the attending physician, or the physician’s delegee authorized under 42 CFR 483.30(e) (relating to physician services).

 (e)  [Reserved].

 (f)  Residents shall be permitted to purchase prescribed medications from the pharmacy of their choice. If the resident does not use the pharmacy that usually services the facility, the resident is responsible for securing the medications and for assuring that applicable pharmacy regulations and facility policies are met. The facility:

   (1)  Shall notify the resident or the resident representative, at admission and as necessary throughout the resident’s stay in the facility, of the right to purchase medications from a pharmacy of the resident’s choice as well as the resident’s and pharmacy’s responsibility to comply with the facility’s policies and Federal and State laws regarding packaging and labeling requirements.

   (2)  Shall have procedures for receipt of medications from outside pharmacies including requirements for ensuring accuracy and accountability. Procedures shall include the review of medications for labeling requirements, dosage and instructions for use by licensed individuals who are authorized to administer medications.

   (3)  Shall ensure that the pharmacist or pharmacy consultant will receive a monthly resident medication profile from the selected pharmacy provider.

   (4)  Shall have a policy regarding the procurement of medications in urgent situations. Facilities may order a 7-day supply from a contract pharmacy if the resident’s selected pharmacy is not able to comply with these provisions.

 (g)  [Reserved].

 (h)  [Reserved].

 (i)  [Reserved].

 (j)  [Reserved].

 (j.1)  The facility shall have written policies and procedures for the disposition of medications that address all of the following:

   (1)  Timely and safe identification and removal of medications for disposition.

   (2)  Identification of storage methods for medications awaiting final disposition.

   (3)  Control and accountability of medications awaiting final disposition consistent with standards of practice.

   (4)  Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.

   (5)  A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

 (k)  The oversight of pharmaceutical services shall be the responsibility of the quality assurance committee. Arrangements shall be made for the pharmacist responsible for the adequacy and accuracy of the services to have committee input. The quality assurance committee, with input from the pharmacist, shall develop written policies and procedures for drug therapy, distribution, administration, control, accountability and use.

 (l)  A facility shall have at least one emergency medication kit that is readily available to staff. The kit used in the facility shall be governed by the following:

   (1)  The facility shall have written policies and procedures pertaining to the use, content, storage, security, refill of and inventory tracking for the kits.

   (2)  The quantity and categories of medications and equipment in the kits shall be based on the immediate needs of the facility and criteria for the contents of the emergency medication kits shall be reviewed not less than annually.

   (3)  The emergency medication kits shall be under the control of a practitioner authorized to dispense or prescribe medications under the Pharmacy Act (63 P.S. § §  390-1—390-13).

   (4)  [Reserved].


   The provisions of this §  211.9 amended under sections 102, 201(12), 601, 801.1 and 803 of the Health Care Facilities Act (35 P.S. § §  448.102, 448.201(12), 448.601, 448.801a and 448.803); and section 2102(a) and (g) of The Administrative Code of 1929 (71 P.S. §  532(a) and (g)).


   The provisions of this §  211.9 adopted August 29, 1975, effective September 1, 1975, 5 Pa.B. 2233; amended April 23, 1982, effective April 24, 1982, 12 Pa.B. 1316; amended January 31, 1987, effective July 1, 1987, 17 Pa.B. 514; amended July 23, 1999, effective July 24, 1999, 29 Pa.B. 3999; amended December 23, 2022, effective July 1, 2023, 52 Pa.B. 8098. Immediately preceding text appears at serial pages (352795) to (352796) and (287199).

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