The licensee shall:

(1) Maintain the pharmacy in the hospital in a safe, clean, and sanitary condition;

(2) Provide evidence of current approval of pharmacy services by the Washington state board of pharmacy under chapter 18.64 RCW;

(3) Develop and implement procedures for prescribing, storing, and administering medications according to state and federal laws and rules, including:

(a) Assuring professional staff who prescribe are authorized to prescribe under chapter 69.41 RCW;

(b) Assuring orders and prescriptions for medications administered and self-administered include:

(i) Date and time;

(ii) Type and amount of drug;

(iii) Route of administration;

(iv) Frequency of administration; and

(v) Authentication by professional staff;

(c) Administering drugs;

(d) Self-administering drugs;

(e) Receiving and recording or transcribing verbal or telephone drug orders by authorized staff;

(f) Authenticating verbal and telephone orders by prescriber in a timely manner, not to exceed forty-eight hours for inpatients;

(g) Use of medications and drugs owned by the patient but not dispensed by the hospital pharmacy, including:

(i) Specific written orders;

(ii) Identification and administration of drug;

(iii) Handling, storage and control;

(iv) Disposition; and

(v) Pharmacist and physician inspection and approval prior to patient use to ensure proper identification, lack of deterioration, and consistency with current medication profile;

(h) Maintaining drugs in patient care areas of the hospital including:

(i) Hospital pharmacist or consulting pharmacist responsibility;

(ii) Legible labeling with generic and/or trade name and strength as required by federal and state laws;

(iii) Access only by staff authorized access under hospital policy;

(iv) Storage under appropriate conditions specified by the hospital pharmacist or consulting pharmacist, including provisions for:

(A) Storing medicines, poisons, and other drugs in a specifically designated, well-illuminated, secure space;

(B) Separating internal and external stock drugs; and

(C) Storing Schedule II drugs in a separate locked drawer, compartment, cabinet, or safe; and

(i) Preparing drugs in designated rooms with ample light, ventilation, sink or lavatory, and sufficient work area;

(j) Prohibiting the administration of outdated or deteriorated drugs, as indicated by label;

(k) Restricting access to pharmacy stock of drugs to:

(i) Legally authorized pharmacy staff; and

(ii) Except for Schedule II drugs, to a registered nurse designated by the hospital when all of the following conditions are met:

(A) The pharmacist is absent from the hospital;

(B) Drugs are needed in an emergency, and are not available in floor supplies; and

(C) The registered nurse, not the pharmacist, is accountable for the registered nurse's actions;

(4) The appropriate professional staff committee shall approve all policies and procedures on drugs, after documented consultation with:

(a) The pharmacist or pharmacist consultant directing hospital pharmacy services; and

(b) An advisory group comprised of representatives from the professional staff, hospital administration, and nursing services;

(5) When planning new construction of a pharmacy:

(a) Follow the general design requirements for architectural components, electrical service, lighting, call systems, hardware, interior finishes, heating, plumbing, sewerage, ventilation/air conditioning, and signage in WAC 246-318-540;

(b) Provide housekeeping facilities within or easily accessible to the pharmacy;

(c) Locate pharmacy in a clean, separate, secure room with:

(i) Storage, including locked storage for Schedule II controlled substances;

(ii) All entrances equipped with closers;

(iii) Automatic locking mechanisms on all entrance doors to preclude entrance without a key or combination;

(iv) Perimeter walls of the pharmacy and vault, if used, constructed full height from floor to ceiling;

(v) Security devices or alarm systems for perimeter windows and relites;

(vi) An emergency signal device to signal at a location where twenty-four-hour assistance is available;

(vii) Space for files and clerical functions;

(viii) Break-out area separate from clean areas; and

(ix) Electrical service including emergency power to critical pharmacy areas and equipment;

(d) Provide a general compounding and dispensing unit, room, or area with:

(i) A work counter with impermeable surface;

(ii) A corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter;

(iii) Storage space;

(iv) A refrigeration and freezing unit; and

(v) Space for mobile equipment;

(e) If planning a manufacturing and unit dose packaging area or room, provide with:

(i) Work counter with impermeable surface;

(ii) Corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter; and

(iii) Storage space;

(f) Locate admixture, radiopharmaceuticals, and other sterile compounding room, if planned, in a low traffic, clean area with:

(i) A preparation area;

(ii) A work counter with impermeable surface;

(iii) A corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter;

(iv) Space for mobile equipment;

(v) Storage space;

(vi) A laminar flow hood in admixture area; and

(vii) Shielding and appropriate ventilation according to WAC 246-318-540 (3)(m) for storage and preparation of radiopharmaceuticals;

(g) If a satellite pharmacy is planned, comply with the provisions of:

(i) Subsection (5)(a), (5)(c)(i), (ii), (iii), (iv), (v), and (vi) of this section when drugs will be stored;

(ii) Subsection (5)(c)(vii), (viii), and (ix) of this section, if appropriate; and

(iii) Subsections (5)(d) and (g) of this section if planned;

(h) If a separate outpatient pharmacy is planned, comply with the requirements for a satellite pharmacy including:

(i) Easy access;

(ii) A conveniently located toilet meeting accessibility requirements in WAC 51-20-3100; and

(iii) A private counseling area.