Background: In the 2015 operating budget, the Legislature directed the Pharmacy Quality Assurance Commission (PQAC) to engage in a stakeholder process to develop statutory standards and protocols specific to long-term care pharmacies. During the 2015 interim, PQAC and the Department of Health (DOH) met with stakeholders and interested parties to address the practice of pharmacy in long-term care settings and to develop a report to the Health Care Committees of the Legislature. That report was delivered November 10, 2015 and included draft statutory language provided by the Washington Health Care Association and the Washington State Pharmacy Association.

Three types of long-term care facilities are licensed by the state through the Department of Social and Health Services. These facilities are nursing homes, adult family homes, and assisted living facilities. The level of care provided to residents varies by facility type from nursing homes providing 24-hour supervised nursing care to the occasional nursing care that may be provided by some adult family homes and assisted living facilities. Pharmacy services provided for long-term care facilities are regulated using the same structure provided for regulating retail pharmacies and hospitals; however, the prescribing practitioner and pharmacy for residents of long-term care facilities are usually located off-site.

A chart order is a medication order entered on the chart or medical record of an inpatient or resident of an institutional facility by a prescribing practitioner or his or her designated agent. Chart orders are used in a variety of settings including hospitals and long-term care facilities.

Pharmacists are required to maintain a record of every prescription dispensed at the pharmacy for at least two years. When prescriptions are sent to a pharmacy through a digital or electronic format, pharmacists are required to print a hard copy of the prescription and maintain this copy with their prescription records for a minimum of two years.

Summary of Bill: Provision of Pharmacy Services - Generally. Chart orders must be considered a prescription if they contain: the full name of the patient; the date of issuance; the name, strength, and dosage form of the drug prescribed; directions for use; and an authorized signature which may be provided in written or electronic format. Chart orders may be used in institutional settings including hospitals, long-term care facilities, hospice programs, mental health facilities, drug abuse treatment centers, residential habilitation centers, or correctional facilities.

When a pharmacy receives a prescription in digital or electronic format, the digital or electronic record may substitute for a hard copy of the prescription for record keeping purposes. The electronic copy must be filed in a form that permits the information to be readily retrievable.

Provision of Pharmacy Services - Long-Term Care Facilities. A licensed nurse, pharmacist, or physician practicing in a long-term care facility or hospice program may act as a practitioner's agent to document a chart order in the patient's medical record pending the prescribing practitioner's signature and may communicate a prescription to a pharmacy. A pharmacy may dispense prescription drugs to a resident of a long-term care facility or hospice program on the basis of a written or electronic prescription or chart order. A nurse, pharmacist, or physician receiving and recording an oral medication order may communicate that order to a pharmacy on behalf of the prescribing practitioner. Prescriptions for Schedule III, IV, or V controlled substances for a resident of a long-term care facility or hospice program may be communicated to the pharmacy by an authorized agent of the prescriber. Authorized agents include registered nurses, pharmacists, or physicians working at the facility or program.

A pharmacy or pharmacist may provide a limited quantity of drugs to a nursing home or hospice program to be used in emergency kits and to be administered under a prescription by authorized facility personnel. These drugs must meet the immediate therapeutic needs of residents or patients and not be available from another source. If a nursing home uses a unit dose drug distribution system, it may maintain a supplemental dose kit for supplemental nonemergency drug therapy. The types of drugs that may be used in emergency kits and supplemental dose kits must be determined by a pharmaceutical services committee whose membership must include a pharmacist, a physician, or an osteopathic physician, and representatives of the nursing home or hospice program. Emergency kits and supplemental dose kits may be restocked by a licensed practical nurse operating under the supervision of a pharmacist.

Shared pharmacy services allow a pharmacy to request another pharmacy to fill a prescription or drug order. These services may be used to ensure that drugs or devices are available to meet the immediate needs of residents of a long-term care facility or hospice program. The supplying pharmacy must keep a copy of the prescription or order on file and must notify the outsourcing pharmacy of the service provided.

A pharmacy may repackage and dispense unused drugs returned by a long-term care facility or hospice program if the drugs are in per-use, blister packaging.

A closed door long-term care pharmacy is a pharmacy that provides pharmaceutical care to a defined and exclusive group of patients who access the pharmacy's services through the long-term care facility or hospice program through which they receive care. Closed door long-term care pharmacies do not provide services to the general public. PQAC must establish the ratio of pharmacists to pharmacy ancillary personnel in a closed door long-term care pharmacy, and may not consider administrative long-term care pharmacy personnel as practicing pharmacy technicians or pharmacy assistants requiring pharmacist oversight while performing administrative tasks.

Staff Summary of Public Testimony: PRO: This bill is the result of a collaborative effort. It will ensure patients in long-term care settings will receive timely and safe access to their medications which will lead to improved outcomes and efficiencies by allowing staff to work as a team. Nursing home residents should not be required to sign agreements forcing them to become customers of a certain pharmacy. Administrative functions should be addressed in current regulations. This bill will provide clarity to the practice of long-term care pharmacy. The bill considers the reality of practice in a long-term care setting and ensures patient safety with a long-term care facility. This bill solves a huge problem in that the pharmacy statutes have not been updated to reflect the current practice of pharmacy. The provision permitting repacking and dispensing of unused drugs is silent on disposal of medication. The bill addresses Schedule III through V drugs, but does not address Schedule II drugs which are currently allowed to be partially filled. The requirement that the provider state whether the medication is ongoing is a departure from current practice; the order should be considered open unless it is otherwise specified.