CMS SOM App. A, Tag A-0489

The hospital must have pharmaceutical services that meet the needs of the patients. The

institution must have a pharmacy directed by a registered pharmacist or a drug storage

area under competent supervision. The medical staff is responsible for developing policies

and procedures that minimize drug errors. This function may be delegated to the

hospital’s organized pharmaceutical service.

Interpretive Guidelines §482.25

A hospital must provide pharmaceutical services that meet the needs of its patients. The services

must include either a pharmacy that is directed by a pharmacist, or, when appropriate, a drug

storage area that is competently supervised. The hospital’s medical staff is responsible for

developing pharmaceutical policies and procedures that minimize the potential for medication

errors, but may delegate this function to the pharmaceutical service.

The manner or degree of noncompliance with the requirements of this Condition and its

component standards must be evaluated to determine whether there is substantial noncompliance

with the Condition, warranting a Condition-level citation.