Background:

Pharmacy Quality Assurance Commission Report.

The 2015-17 operating budget directed the Pharmacy Quality Assurance Commission (Commission) to use a stakeholder process to adopt statutory standards and protocols for long-term care pharmacies. The proposal was due to the committees of the Legislature with jurisdiction over health care by November 15, 2015. The proviso also directed the Commission and the Department of Health, when inspecting long-term care facilities, to acknowledge the relationship between the practitioner, the long-term care facility registered nurse, and the pharmacist in conveying chart orders to a long-term care pharmacy.

The report was submitted on November 12, 2015, and expressed the Commission's support for a statutory proposal that addressed the communication and transmission of chart orders to long-term care pharmacies, the use of emergency kits and supplemental dose kits, the use of automated drug distribution devices, the storage of prescription records, the repackaging and dispensing of unused, returned drugs, and shared pharmacy services.

Nursing Home Prescriptions.

Nursing homes must either employ a licensed pharmacist or have a written agreement with a licensed pharmacist to advise the nursing home on ordering, storage, administration, disposal, and recordkeeping of drugs and biological products. Nursing home resident medications are ordered by staff physicians or authorized practitioners, including registered nurses, osteopathic physician assistants, or physician assistants. The orders may be written or oral.

Emergency Kits and Supplemental Dose Kits.

Commission regulations allow nursing homes to have emergency kits and supplemental dose kits. Emergency kits are to be used in emergencies when medications cannot be obtained from a pharmacy in a timely manner. The pharmaceutical services committee of the nursing home determines the contents and quantity of drugs in the emergency kit and assumes responsibility for its proper storage, security, and accountability. Supplemental dose kits are allowed in nursing homes that use a unit dose drug distribution system when supplemental nonemergency drug therapies are not available from the pharmacy in a timely manner. A unit dose drug distribution system is a method of dispensing drugs in a package that is ready to administer to the resident.

Pharmacy to Pharmacy Technician Ratios.

Pharmacy technicians are trained to perform nondiscretionary functions associated with the practice of pharmacy. A pharmacist may not supervise more than one pharmacy technician, except in connection with certain residential facilities in which a pharmacist may supervise up to three pharmacy technicians if preparing medications used by patients within the facility. Under Commission standards, when pharmacy services are provided to inpatients of an extended care facility, a pharmacist who is practicing outside of the confines of the pharmacy may be included in the ratio if there are enough pharmacists to properly supervise the pharmacy technicians, the pharmacy is not open to the public, medications are checked by another health care professional before being given to the patient, and drug orders are not dispensed without being checked by a pharmacist or pharmacy intern.

Summary of Bill:

Chart Orders.

"Chart orders" are defined as orders for a drug or device entered on the chart or medical record of an inpatient or resident of an institutional facility by a practitioner or his or her designated agent. The term "institutional facility" relates to organizations with the primary purpose of providing a physical environment for patients to obtain health care services. The term includes hospitals, nursing homes, assisted living facilities, adult family homes, hospice programs, mental health facilities, drug abuse treatment centers, residential habilitation centers, and correctional facilities.

Chart orders are 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.

An authorized signature may be written or electronic and be that of either the prescribing practitioner or, if the name of the prescribing practitioner is included, his or her authorized agent. A licensed nurse, pharmacist, or physician practicing in a long-term care facility or hospice program may act as the practitioner's agent without the need for a written agency agreement when: (1) documenting a chart order on behalf of the prescribing practitioner, pending the practitioner's signature; or (2) communicating a prescription to a pharmacy.

A pharmacy may resupply a legend drug to a patient at a long-term care facility or hospice program pursuant to a chart order that: (1) is signed by the prescribing practitioner; (2) is not time limited; and (3) has not been discontinued.

Emergency Kits and Supplemental Dose Kits.

Pharmacists may provide, without a prescription, a limited amount of drugs to nursing homes and hospice programs for emergency administration to residents with a prescription. The drugs must be of a type required for immediate therapeutic needs and not available from an authorized source in a timely manner.

If a nursing home maintains a unit dose drug distribution system, it may maintain a supplemental dose kit for supplemental nonemergency drug therapy.

The types and amounts of drugs in emergency kits and supplemental dose kits are to be determined by a nursing home or hospice program's pharmaceutical services committee. Emergency kits and supplemental dose kits must be stored in a way that prevents unauthorized access and preserves the drugs.

Pharmacist to Pharmacy Technician Ratios.

The term "closed door long-term care pharmacy" refers to a pharmacy that has a defined group of patients who are associated with a long-term care facility or hospice program and does not sell products to the general public. The Pharmacy Quality Assurance Commission (Commission) must adopt reasonable, task-based standards for determining the ratio of pharmacists to pharmacy technicians in closed door long-term care pharmacies. The standards may not consider pharmacy technicians within the ratio if they are performing administrative tasks that are not related to the immediate dispensing of drugs, such as medical records maintenance, inventory control, delivery, or processing of returned drugs.

Shared Pharmacy Services.

Shared pharmacy services allow another pharmacy to process or fill a prescription or drug order for an outstanding pharmacy. Services may include preparing, packaging, compounding, dispensing, or reviewing chart orders.

Pharmacies may outsource shared pharmacy services for a long-term care facility or hospice program to another pharmacy. The outsourcing pharmacy must obtain the approval of the long-term care pharmacy or hospice program and provide a copy of the prescriptions or orders to the other pharmacy prior to outsourcing the services. Shared pharmacy services may be used for ensuring: (1) the availability of drugs to meet the immediate needs of residents, or (2) the continuation of pharmacy services when the outsourcing pharmacy cannot provide services on an ongoing basis. If the other pharmacy is providing a first dose or partial fill of a prescription or drug order because the outsourcing pharmacy is unable to meet a patient's immediate needs, the outsourcing pharmacy is not required to fully transfer the prescription or drug order.

General Pharmacy Provisions.

When a pharmacy receives an exact visual image of a prescription in digital or electronic format, the digital or electronic record constitutes a record of prescription as long as the original is digitally referenced, dated, and filed so that it is readily retrievable.

Pharmacies are permitted to repackage and dispense unused drugs that are returned by long-term care facilities or hospice programs if they are in per-use, blister packaging. The Commission must adopt rules for safe and efficient repackaging, reuse, and disposal of unused drugs.

Pharmacists approved by the Commission may order medications for nursing home residents. An exception to the requirement that orders for medications at nursing homes be limited by time is allowed in cases in which a physician or authorized practitioner specifies that the order continue in effect until discontinued.

Licensed nurses, pharmacists, and other physicians may communicate oral medication orders to a pharmacy on behalf of the ordering physician or authorized practitioner. The communication may occur by telephone, by facsimile, or by electronic communication.

Electronic communications of prescription information must include an opportunity for a practitioner to indicate their preference on whether or not an interchangeable biological product may be substituted.

References to the Board of Pharmacy are changed to the Pharmacy Quality Assurance Commission.