Board of Pharmacy

Administrative Rules for Remote Pharmacies and Emergencies

Version 12 January 18, 2013

discussion points??? from my notes:

Ideas for Remote Pharmacy Rules

dispensed by certified pharm. tech. employed by pharmacy

pharm. tech must be HIPAA qualified and trained

limits on drugs to be used

mandatory counseling for each prescription

input of information: credit card, third party reimbursement, post scripts etc.

-define under-served area: define by volume, a certain level may create a requirement for a brick and mortar facility. Mileage radius

limit how many sites one pharmacist can cover (while running a pharmacist)

Q: pharm. students involved with.

Do we need to be consistent on the use of the terms “pharmacist in charge, managing pharmacist, [coordinating pharmacist manager our choice May 2, 2012], supervising pharmacist.”

emergency rules:

Need to vet the emergency rules with Public Safety, Health Dept., Governor’s office, BISHCA (re insurance and pre-filing)

how to handle evacuations, early fills etc.

Mike O’Neil, Vermont Emergency Management

strategic national stockpile

vetting rules: consult FEMA

See Louisiana and Mississippi rules for possible inspiration, and Florida(!!)

Chris Bell, Department of Health. Director Public health preparedness and something else

what about: strategic stockpile. E.g. statewide distribution of pills.

Research emergency management statutes and rules, as well as DOH.

Should there be some way for pharmacies to mark people who may need drugs in an emergency.

Vermont emergency management web site has links to important sites.

Can governor’s office suspend rules or something to allow insurance to pay for drugs released early.

Pre-disaster declarations as triggering certain rules (e.g. insurance will still have to pay for them)

Part 19 Remote Pharmacies

19.1 General Purpose:

(a) This Part is enacted pursuant to 26 V.S.A. § 2032 which initially authorized the Board of Pharmacy to conduct pilot remote pharmacy experiments and to then propose rules governing remote pharmacy and remote pharmacy practice.

(b) The Board’s experiment shows that residents of identified under-served areas of Vermont can benefit from having access to remote pharmacies. [additional findings here] Vermonters in under-served areas are significantly restricted in their ability to obtain needed prescription drugs. Remote pharmacies enable Vermonters to obtain prescription drugs in their own communities while still being able to consult with a pharmacist in a manner where public health, safety and welfare can be assured.

(c) Remote pharmacies should be located only in those areas where residents require basic pharmacy services and do not have a reasonably accessible retail pharmacy nearby. Remote pharmacies are designed to allow patients to, as closely as possible, receive the basic care, attention, and services that they would expect from a traditional retail pharmacy. Because a pharmacist is not required to be on the premises at all times however, the remote pharmacy cannot without additional communication aids provide the full range of services normally provided by a retail pharmacy.

(d) Remote pharmacies are not intended to be a substitute for retail pharmacies where a pharmacist is present whenever prescription drugs are dispensed.

a remote pharmacy is not necessarily intended to provide permanent ??? how do we make it so that it may be only for limited duration.

19.2 Definitions

(a) “AMDS” means automated medication distribution system, that is an automated device or series of devices operated by an electronic interface with one of more computers that is used to prepare, package, or dispense specified dosage units of drugs for administration or dispensing to a patient or the ultimate user. “AMDS” includes a device that prepares and packages a drug for unit dose dispensing, that prepares and packages a drug into outpatient prescription vials, and that dispenses pre-packaged drugs.

(b) “Certified pharmacy technician” means an individual who is registered with the Board as a pharmacy technician and whose registration is unencumbered and who has obtained and maintains current certification from a national technician certification authority approved by the Board.

(d) “Coordinating Pharmacy” means a licensed pharmacy located within the State of Vermont providing remote pharmacy services at one or more licensed remote dispensing/pharmacy sites.

(e) “Coordinating pharmacist” means a Vermont licensed pharmacist with an unencumbered license who provides remote pharmacy services and who has no less than three years licensed practice experience.

(f) “Coordinating Pharmacist Manager” means a Vermont licensed pharmacist who has full responsibility for all aspects of one or more remote pharmacies.

(g) “Remote Pharmacy” means a licensed pharmacy facility where pharmacy services are provided by a coordinating pharmacist. The remote pharmacy is designed so that a pharmacist at a different location provides pharmacy services electronically via a computer system and via video and audio communication system approved by the Board.

(h) “Remote pharmacy practice” means the provision of pharmaceutical care services, including the storage and dispensing of prescription drugs, drug regimen review, and patient counseling, at a staffed remote dispensing site.

(i) “These rules” means the Administrative Rules of the Board of Pharmacy

19.3 Coordinating Pharmacist Manager

(a) The Coordinating pharmacist manager is a Vermont licensed pharmacist who:

1) has no less than three years licensed practice experience;

2) possesses an unencumbered license; and

3) has been specifically designated and registered with the Board as the coordinating pharmacist manager.

(b) When the remote pharmacy is affiliated with a Vermont retail pharmacy, the retail pharmacy’s pharmacist manager shall be the coordinating pharmacist manager.

(c) The manager of the coordinating pharmacy shall also serve as the coordinating pharmacist manager of the remote dispensing site.

19.4 Change of Coordinating Pharmacist Manager Changes in the coordinating pharmacist manager are reported to the Board as are changes in pharmacist managers in Part 6 of these rules.

19.5 Coordinating Pharmacist Manager Responsibilities The coordinating pharmacist manager shall be responsible for, at a minimum, the following:

(a) Submitting for Board approval the operational plan for the remote pharmacy service, including:

(1) justification of the need for the remote pharmacy service as provided in this Part.

(2) identification of the coordinating site;

(3) identification of the remote dispensing site;

(4) the names and titles of key personnel at both locations;

(5) the quality assurance and improvement plan;

(6) policies and procedures as provided in rule; and

(7) explanation of the remote dispensing process to be utilized at the remote dispensing site;

(b) Maintaining all licenses and registrations required for operation of the coordinating pharmacy and of the remote pharmacy.

(c) Ensuring that the practice of pharmacy performed at the remote pharmacy and the supervision of pharmacy technicians complies applicable federal and state laws and regulations and these rules.

(d) Ensuring that

(1) any automated pharmacy system is in good working order;

(2) the AMDS accurately dispenses the correct strength, dosage form, and quantity of the prescribed drug and accurately prints the prescription label;

(3) while maintaining appropriate record-keeping, security, and quality assurance safeguards.

(e) Ensuring that all pharmacists and pharmacy technicians authorized to provide remote pharmacy services at the managing pharmacy or the remote site maintain current licensure or registration with the Board and are trained in the operation of any automated pharmacy system and familiar with policies and procedures relating to the remote pharmacy practice.

19.5 Duties of Coordinating Pharmacist The following activities shall be performed only by the coordinating pharmacist. These activities may not be delegated to a pharmacy technician at a remote site.

(a) Receiving an oral prescription drug order from a prescriber or the prescriber’s agent for dispensing to a patient at the remote site;

(b) Interpreting a prescription drug order;

(d) Interpreting the patient’s drug record and conducting a drug utilization review;

(e) Authorizing any AMDS to dispense a prescription drug and print a prescription label at the remote site;

(f) Performing the final verification of a dispensed prescription; to ensure that the prescription drug order has been accurately dispensed as prescribed.

(g) Counseling the patient or the patient’s care-giver; and

(h) Completing and documenting the weekly inspection of the remote site.

19.6 Written or Electronic Prescription drug orders

(a) A remote dispensing site may receive only written, faxed, or electronic prescription drug orders. The pharmacy technician at the remote site shall either transmit the prescription drug order or refill request to the coordinating pharmacy. The pharmacy technician may input the prescription drug order or refill request so that the pharmacist at the coordinating pharmacy may perform a prospective drug use review and verify the prescription information prior to authorizing dispensing at the remote site.

(b) A pharmacy technician at a remote site shall not receive oral prescription drug orders from a prescriber or prescriber’s agent. Oral prescription drug orders shall be communicated directly to a coordinating pharmacist.

19.7 License Required for Remote Pharmacy Services - General Requirements

(a) To be eligible for a remote pharmacy license, the applicant shall comply with the application process set forth in Rules 7.2 and Rule 7.3 herein and demonstrate to the Board that there is limited access to pharmacy services in the community where the remote site is proposed.

(b) In determining whether a community has limited access to pharmacy services, the board may consider, but is not limited to the following factors:

(1) the proximity of a licensed retail or remote pharmacy;

(2) the geographical location of the community and proximity or ease of access to a retail pharmacy;

(3) nature of the community and its demographics;

(4) the availability of a licensed pharmacist in the community;

(c) In no event will the Board approve a remote pharmacy if a retail pharmacy is located within fifteen (15) miles drive by motor vehicle.

[Grandfather clause for pilot project remote pharmacies]

(d) Remote pharmacies approved by the Board as part of the pilot project before adoption of these rules may, so long that they remain in compliance with these rules, remain in operation at their present locations.

19.8 Laws applying to remote pharmacies

(a) Each remote pharmacy shall, in addition to meeting the requirements of these rules, comply with all applicable federal and state laws.

(b) If controlled substances are dispensed from the remote pharmacy, the remote pharmacy must obtain its own DEA number and registration.

(c) Where remote pharmacy rules conflict with the other rules governing retail pharmacies, the requirements of this Part shall apply. Space requirements for retail pharmacies do not apply to remote pharmacies.

19.9 Sign at remote pharmacy

(a) Each remote pharmacy shall have a clearly visible sign stating: “This is a licensed remote pharmacy. A pharmacist may not be physically present. A pharmacist from the [name of coordinating pharmacy] pharmacy in [location] reviews every prescription dispensed here. Whether physically present here or at the [name of coordinating pharmacy] pharmacy, the pharmacist is required to speak with you before your prescription will be dispensed.”

(b) The license, or a copy thereof, of any pharmacist providing remote pharmacy services must be

prominently displayed at the remote pharmacy.

(d) Remote pharmacies must display all signs required by state or federal law for any retail pharmacy.

19.10 Remote Pharmacy Staffing

(a) A pharmacist, pharmacy technician, or pharmacy intern performing services in support of a remote pharmacy, whether those services are performed at the central pharmacy or the remote pharmacy, must be licensed by or registered with the Board.

(b) A Pharmacist who is engaged in the operation of a retail or mail order pharmacy shall not simultaneously operate more than one remote pharmacy.

(c) A pharmacist who is not engaged in the operation of a retail pharmacy may operate no more than three simultaneously open Remote Pharmacies.

(d) A coordinating pharmacy providing remote pharmacy services shall provide sufficient staffing to meet the prescription work load.

(e) In an emergency a temporary exception to this limit may be granted by the Board or its designee in situations where the Coordinating Pharmacy has documented a need to supervise additional Remote Pharmacies or Remote Dispensing Sites and has demonstrated that appropriate safeguards are in place to ensure proper supervision of each.

19.5 Remote Pharmacy Staffing Remote Pharmacies are staffed by nationally Certified Pharmacy Technicians registered with the Board or by Pharmacy Interns registered with the Board who shall be under the continuous supervision of a Pharmacist at the Coordinating Pharmacy at all times that it is open to provide pharmacy services. ok to delete

xx.x Staffing / Supervision Any time the Remote pharmacy is in operation:

19.5 Compliance with Federal Law A Coordinating Pharmacy shall comply with appropriate federal and state controlled substance registrations for each Remote Pharmacy or Remote Dispensing Site if controlled substances are maintained.

19.11 Remote pharmacy closing A Coordinating Pharmacy shall comply with the drug outlet closing provisions of these Rules.

19.12 Audiovisual link.

(a) There must be a continuously accessible, two-way audiovisual link between the central pharmacy and the remote pharmacy. The transmission of information through the computer link must make information available to the central pharmacy and the remote pharmacy simultaneously. The video camera used for the certification of prescriptions must be of sufficient quality and resolution so that the certifying pharmacist can visually identify the markings on tablets and capsules. No prescription may be dispensed if the audio/visual link is not fully operational.

(b) Audio/video and IT communications disruptions shall be documented and retained for three years.

(c) The audio/visual link shall be recorded while the remote pharmacy is in operation with the recording being retained for 30 days.

(d) Each remote pharmacy shall have security cameras which shall capture movement within the remote pharmacy at all times. The coordinating pharmacy shall be able to monitor the security cameras at all times.

19.13 Remote Dispensing Site A Remote Dispensing Site may utilize an Automated Pharmacy System located in an area accessible only to authorized personnel.

19.14 Remote Pharmacies

(a) Remote pharmacies are principally staffed by Certified Pharmacy Technicians under the continuous supervision of a Pharmacist.

(b) Pharm interns may not work at a remote pharmacy unless a pharmacist is physically present at the remote pharmacy.

(c) The Pharmacist at the Coordinating Pharmacy shall have access to the Remote Pharmacy’s automated data processing system to perform a Prospective Drug Utilization Review (DUR) prior to Dispensing. The Pharmacist shall ensure, through the use of the video/auditory communication system, that the Certified Pharmacy Technician has accurately and correctly prepared the Drug for Dispensing according to the Prescription Drug Order.

(d) The remote pharmacy may only be open if a computer link, video link, and audio link with the coordinating pharmacy are functioning properly. If any link is not functioning properly, the remote pharmacy must be closed unless a pharmacist is working at the remote pharmacy; [keep?]

(e) No remote pharmacy may be open when the coordinating pharmacy is closed, unless a licensed pharmacist is working at the remote pharmacy;

(f) Any prescription filled at the remote pharmacy must be reviewed, interpreted by a pharmacist at the coordinating pharmacy before the prescription is dispensed;

(g) Any remotely dispensed prescriptions must have a properly prepared label attached to the final drug container before the pharmacist certifies the dispensing process.

(h) The computer must be capable of carrying the initials of the technician preparing the prescription and the pharmacist verifying the prescription.

(i) Unless the patient affirmatively refuses counseling, which refusal shall be documented, counseling is required for all prescriptions.

19.15 Limitation on Remote Pharmacies A remote pharmacy may not receive “take backs” except drugs returned due to a prescription dispensing error made at that site.

19.16 Security Drugs stored at Remote pharmacy shall be stored in an area that is:

(a) separate from any other Drugs at a health care facility; and

(b) locked by key or combination, so as to prevent access by unauthorized personnel.

(c) Access to the area where Drugs are stored at the Remote Pharmacy must be limited to Pharmacists, Certified Pharmacy Technicians, or Pharmacy Interns who are employed by the Coordinating Pharmacy or by the institutional facility.

19.14 Delivery to Remote Pharmacies The coordinating pharmacy shall have a procedure governing delivery of drugs to remote pharmacies. The procedure shall be available for Board review or inspection on request.

19.17 Policy and Procedure Manual The Coordinating Pharmacy and Remote Pharmacy shall operate in compliance with written policy and procedure manual that is established by the Coordinating Pharmacy. The policy and procedure manual shall include, but is not be limited to the following:

(a) a current list containing the name and business address of the Coordinating Pharmacist and personnel designated by the Pharmacist-in-Charge to have access to the area where Drugs are stored at the Remote Pharmacy or Remote Dispensing Site;

(b) duties that may only be performed by a Pharmacist;

(c) a copy of the written agreement between the Coordinating Pharmacy and the Remote Pharmacy or between the Coordinating Pharmacy and the Institutional Facility or clinic where the Remote Dispensing Site is located. Such contract or agreement is not required if the Remote Pharmacy or Remote Dispensing Site are under common control or ownership of the Coordinating Pharmacy;

(d) date of last review and revision of policy and procedure manual; and

(e) policies and procedures for:

(1) operation of the video/auditory communication system;

(2) security;

(3) sanitation;

(4) storage of Drugs;

(5) Dispensing;

(6) supervision; and

(7) Drug procurement, receipt of Drugs, and Delivery of Drugs.

19.18 Record keeping.

(a) A Coordinating Pharmacy providing pharmacy services at a Remote Pharmacy shall, at least annually, review and revise as necessary its written policies and procedures, and document such review.

19.19 Filling CII Dispensing of CII prescriptions shall follow the following protocol:

(a) patient presents original hard copy of CII prescription to the remote pharmacy; (faxed prescriptions are not permitted)

(b) after verifying that the prescribed drug is in stock, technician dates, cancels, and signs the original hard copy;

(d) coordinating pharmacist prints and reviews scanned prescription.

(e) Pharmacist dates, cancels, and signs the printed scanned prescription;

(f) pharmacist re-scans the prescription to the patient file;

(g) the tech at the remote site prints the pharmacist’s cancelled prescription and attaches

it to the original prescription.

(h) No less than once per week, the original prescription must be reviewed in person by a pharmacist who then cancels, signs, and dates the original prescription.

19.20 Inspections and Board of Pharmacy Access to Records

(a) All policies and procedures for any remote pharmacy must be maintained both in the coordinating pharmacy and the remote pharmacy and be available for inspection by the Board. The Board may physically inspect a remote pharmacy as it deems appropriate.

19.21 Quality Assurance The coordinating pharmacist manager must:

(a) Conduct an inspection of the remote pharmacy shall be conducted by a licensed pharmacist at weekly intervals or more when necessary. Inspection must be documented and kept on file at the remote pharmacy and available upon request by the board;

(b) Implement and conduct a quality assurance plan that provides for on-going review of dispensing errors, with appropriate action taken, if necessary, to assure patient safety;

(c) Verify controlled substance prescriptions for both accuracy and legitimacy of the original prescription by the pharmacist-in-charge or a designated pharmacist during weekly inspection visits;

(d) Maintain records of all controlled substances stocked by the remote pharmacy through a daily perpetual inventory. Controlled substance perpetual inventory records must be available for inspection by the board’s inspectors.

(e) Conduct an inventory of all controlled substances at least monthly to verify accuracy.

(f) Maintain a record of medication errors.

19.22 Reports to the Board

(a) Initial report to the Board. After 180 days of operation the coordinating pharmacist manager for each remote pharmacy shall submit a report to the board. The report shall:

(1) summarize identified errors by category and shall include the total number of errors identified, the reasons for the errors, the corrective actions taken to prevent the recurrence of those errors.

(2) state the number of prescriptions dispensed each month.

(b) Subsequent reports, annually. Within 15 days of the anniversary of the opening date, the coordinating pharmacist manager for each remote pharmacy shall submit a report to the Board. The report shall contain all the information required in subsection (a) of this rule.

19.23 Renewal requirements: no expectation of perpetuity, no right to renewal, only if the area remains under-served. convert to retail, or die.

(a) Before a remote pharmacy license will be renewed, the licensee must demonstrate a continuing need for the remote pharmacy addressing the criteria upon which the initial license was granted. The Board’s renewal form may contain questions to assist the renewal evaluation process so that the Board can determine whether there is a continuing need for the remote pharmacy.

(b) Remote renewals applications must be submitted using forms approved by the board.

19.24 Termination of remote pharmacy

maximum number of prescriptions filled will require a retail pharmacy???

or:

A remote pharmacy license will be not be renewed? [withdrawn] by the Board if a new retail pharmacy is granted a license to operate within fifteen (15) miles by motor vehicle of the remote pharmacy site??? move this-LN

19.25 Automated Medication Distribution System A remote pharmacy which utilizes an AMDS must:

(a) be operated pursuant to policies and procedures adopted by the coordinating pharmacy. The policies and procedures shall be maintained on site in the Pharmacy (or Coordinating Pharmacy) for review by the Board of Pharmacy.

(b) The policies and procedures shall require on-going documentation by the coordinating pharmacist manager to assure:

(1) that the automated pharmacy dispensing system is in good working order

and accurately dispenses the correct strength, dosage form, and quantity of the drug prescribed

(2) appropriate record keeping and security safeguards, and

(3) a mechanism for securing and accounting for medications removed from and subsequently returned to the Automated Pharmacy System; and

(4) a mechanism for securing and accounting for wasted medications or discarded medications.

19.26 APS Records Records and/or electronic data kept by Automated Pharmacy Systems shall:

(a) be maintained at the AMDS site and must be readily available to the Board. Such records shall include:

(1) identification of the individual accessing the system;

(2) the name, strength, dosage form, and quantity of the Drug accessed;

(3) the name of the patient for whom the Drug was ordered; and

(4) A record of medications filled/stocked into an Automated Pharmacy System and identification of the persons filling/stocking and checking for accuracy.

(5) such additional information as the coordinating pharmacist may deem necessary.

19.27 APS Coordinating Pharmacist Manager Duties The coordinating pharmacist shall have the sole responsibility to assign, discontinue, or change access to the system.

one or more qualified certified pharmacy technicians