Section 250.2110  Service Requirements

a)         The hospital shall have pharmaceutical services that meet the needs of the patients.  This service shall include a pharmacy directed by a registered pharmacist and may have a drug storage area under pharmacy supervision.

b)         A pharmacy or pharmaceutical policy and procedure manual, developed by the Pharmacy and Therapeutics Committee, shall identify the Service (system) and manner of operations that minimize drug errors.

c)         The service shall be under the direction of a registered pharmacist employed by the hospital on a full-time, a part-time or consulting basis. Responsibilities of the pharmacist must be identified in the Policy and Procedure Manual or other document and administered in accordance with accepted professional principles.

d)         A pharmacy shall be staffed at all times by a registered pharmacist during open hours.  At all other times, the pharmacy shall be locked. Provisions must be made for a pharmacist or pharmaceutical service on call during times when the pharmacy is not open.

e)         When a pharmacist is absent from the hospital, a registered professional nurse may have access to the pharmacy.  The nurse may obtain a single dose, manufacturer's original package, or container prepackaged under the supervision of a pharmacist of a drug or medication, necessary to administer to a patient in carrying out treatment and medication orders of a prescriber.  A signed receipt for the drugs and medicines removed shall be left for the pharmacist.

f)         Automated dispensing and storage systems for the storage and supply of drugs, used in the facility, shall be stocked only under the supervision of a pharmacist.  They shall be securely locked, shall provide a record of what was supplied, to whom and for which patient.  The drugs contained therein may be released from the machines only by a nurse, APRN, physician assistant, physician, pharmacist, or other designated health care professional as identified by the hospital's pharmacy and therapeutics committee.

g)         All drugs and medicines shall be stored and dispensed in accordance with applicable State and Federal laws and regulations.

h)         All compounding, packaging, and dispensing of drugs and biologicals shall be under the supervision of a pharmacist and performed consistent with State and federal laws.

(Source:  Amended at 49 Ill. Reg. 14395, effective October 27, 2025)