CMS SOM App. A, Tag A-0490

§482.25 Condition of Participation: Pharmaceutical Services.

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

Interpretive Guidelines §482.25

What is included in pharmaceutical services?

Pharmaceutical services encompass the functions of procuring, storing, compounding, re-packaging, and dispensing all medications, biologicals, chemicals and medication-related devices

within the hospital. They also include providing medication-related information to care

professionals within the hospital, as well as direct provision of medication-related care.

Meeting patient needs

Hospitals must provide pharmaceutical services that meet the needs of their patients. The scope

and complexity of pharmaceutical services available in the hospital must be consistent with the

volume and types of patients the hospital serves. Except in unusual circumstances, the

pharmaceutical service is expected to make available in a timely manner the volume and types of

medications typically needed. These would be those medications typically prescribed by the

hospital’s practitioners for hospital patients receiving inpatient services, surgical services,

diagnostic services involving medications as a component of testing, and outpatient drug

therapies administered while the patient is in the hospital.

Not every hospital is expected to offer the same level of pharmaceutical services. For example:

• It would not be uncommon for a psychiatric hospital to maintain a relatively limited

pharmaceutical service, due to minimal need for compounding, and/or dispensing

multiple types and forms of medications and biologicals.

• On the other hand, a short-term acute care hospital with a busy oncology outpatient

service and other complex medical and surgical departments would be expected to

provide a wider range of pharmaceutical services that are ready to be furnished when

needed.

Survey Procedures §482.25

• Ask the hospital for evidence of the scope and complexity of its pharmaceutical services.

• Ask how the hospital has determined that the services meet the needs of its patients.

• Ask unit nursing staff if prescribed medications are routinely available and timely. If

there are reports of frequent delays or other problems, probe further with the director of

pharmaceutical services.