18VAC110-20-540. Emergency drug kit.
The pharmacist providing services may prepare an emergency kit for a long-term care facility in which access to the kit is restricted to a licensed nurse, pharmacist, or prescriber and only these licensed individuals may administer a drug taken from the kit and only under the following conditions:
1. The contents of the emergency kit shall be of such a nature that the absence of the drugs would threaten the survival of the patients.
2. The contents of the kit shall be determined by the provider pharmacist in consultation with the medical and nursing staff of the institutions and shall be limited to drugs for administration by injection or inhalation only, except that Nitroglycerin SL and diazepam rectal gel may be included.
3. The kit is sealed in such a manner that it will preclude any possible loss of the drug.
a. The dispensing pharmacy must have a method of sealing such kits so that once the seal is broken, it cannot be reasonably resealed without the breach being detected.
b. If a seal is used, it shall have a unique numeric or
alphanumeric identifier to preclude replication
or both. The pharmacy shall maintain a record of the seal identifiers when
placed on a box or kit and maintain the record until such time as the seal is
c. In lieu of seals, a kit with a built-in mechanism preventing resealing or relocking once opened except by the provider pharmacy is also acceptable.
4. The kit shall have a form to be filled out upon opening the
kit and removing contents to write the name of the person opening the kit, the
date, time and name and quantity of
item(s) items removed. The
opened kit is maintained under secure conditions and returned to the pharmacy
within 72 hours for replenishing.
5. Any drug used from the kit shall be covered by a prescription, signed by the prescriber, when legally required, within 72 hours.