General Pharmacy Policies
All policies on this page updated September 2018 unless otherwise specified.
I. General Policies and Procedures
A. Organization Aspects
IA1 – Provider Pharmacy Requirements
IA2 – Consultant Pharmacist Services Provider Requirements
IA3 – Infusion Therapy Products Provider Requirements
IA4 – Arrangements with Noncontract Pharmacy
B. Medication Orders
IB1 – Non-Controlled Medication Order Documentation
IB2 – Controlled Substance Prescriptions
IB3 – Time Limited Orders
IB4 – Standing Orders (Optional)
C. Medication Ordering and Receiving from Pharmacy
IC1 – Pharmacy Hours and Delivery Schedule
IC2 – Pharmacy Delivery
IC3 – Ordering and Receiving Non-Controlled Medications From the Dispensing Pharmacy
IC4 – Receiving Controlled Substances
IC5 – Emergency Pharmacy Service and Emergency Kits
IC6 – Multiple Source Drug Products
IC7 – Drug Information
IC8 – House-Supplied (Floor Stock) Medications
IC9 – Material Safety Data Sheets (MSDS)
IC10 – Medication Labels
IC11 – Medication Packaging
IC12 – Medication Brought to the Facility by a Resident or Responsible Party
IC13 – Approved Medications
IC14 – Personnel Authorized to Handle Medications in the Facility
D. Medication Storage in the Facility
ID1 – Storage of Medications
ID2 – Controlled Substance Storage
ID3 – Bedside Medication Storage
E. Disposal of Medications and Medication-Related Supplies
IE1 – Controlled Substance Disposal revised 6/2019
IE2 – Discharge with Medications
IE3 – Discontinued Medications
IE4 – Returning Medications to Pharmacy
IE5 – Medication Destruction revised 6/2019
IE6 – Syringe and Needle Disposal
IE7 – EPA Pharmaceutical Waste Storage and Disposal (Optional)
F. Miscellaneous Special Situations
IF1 – Out-On-Pass Medications/Leave of Absence (LOA)
IF2 – Use of Investigational Medications
IF3 – FDA Risk Evaluation and Medication Safety (REMS) Medication Guides
IF4 – Medications Not Covered By Third-Party Payers, Formulary Approval and Therapeutic Substitutions Upon Approval by the Physician
IF5 – Medications Brought to the Facility by Physicians or Residents/Family Members
IF6 – Drug Product Defect Reporting
IF7 – Drug Product Recalls
IF8 – Influenza and Pneumococcal Disease Prevention
IF9 – Box Warning Medications
IF10 – Unavailable Medications
IF11 – Pharmacist-Physician Collaborative Care Agreement (Optional)
IF12 – Low Risk, Not Readily Available, Non-sterile Preparations
II. Medication Administration
A. Preparation and General Guidelines
IIA1 – Equipment and Supplies for Administering Medications
IIA2 – Medication Administration
IIA3 – Vials and Ampules of Injectable Medications
IIA4 – Infusion Therapy Products – General Information
IIA5 – Reconstitution of Medication for Parenteral Administration
IIA6 – Preparation of Emergency or Short-Stability Infusion Therapy Products
IIA7 – Controlled Substances
IIA8 – Irrigation Solutions
IIA9 – General Guidelines for Administering Medication Via Enteral Tube
IIA10 – Self-Administration of Medications
IIA11 – Emergency Dispensing System for First Dose and Emergency Medications
B. Specific Medication Administration
IIB1 – Administration Procedures for All Medications
IIB2 – Oral Medication Administration
IIB3 – Sublingual, Buccal, and Transmucosal Medication Administration
IIB4 – Nasal Administration
IIB5 – Eye Drop Administration
IIB6 – Eye Ointment and Gel Administration
IIB7 – Ear Drop Administration
IIB8 – Oral Inhalation Administration
IIB9 – Rectal Suppository Administration
IIB10 – Rectal Enema Administration
IIB11 – Vaginal Medication Administration
IIB12 – Enteral Tube Medication Administration
IIB13 – Transdermal Drug Delivery System (Patch) Application
IIB14 – Injectable Medication Administration
IIB15 – Infusion Therapy Medication Administration: Medications Added to Infusion Preparations by the Nurse in the Facility
IIB16 – Topical Medication Administration
III. Medication Monitoring
A. Consultant Pharmacist Reports
IIIA1 – Medication Regimen Review
IIIA2 – Documentation and Communication of Consultant Pharmacist Recommendations
B. Medication Monitoring and Management
IIIB1 – Monitoring of Medication Administration
IIIB2 – Medication Management
IIIB3 – Preventing and Detecting Adverse Consequences and Medication Errors
Appendix
Full MACRX Facility Policy and Procedures Document
All Pharmacy Forms and Guides