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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 4729:5-3 | General Provisions

 
 
 
Rule
Rule 4729:5-3-01 | Disposal of controlled substances.
 

(A) As used in this rule:

(1) "Controlled substance" has the same meaning as in section 3719.01 of the Revised Code.

(2) "Controlled substance proof-of-use sheet" means a record that captures, at a minimum, the following information:

(a) Date;

(b) Patient name;

(c) Drug name;

(d) Drug strength;

(e) Quantity; and

(f) The positive identification of the individuals authorized by this rule who are responsible for removing the dangerous drugs from the medication cart, or other storage area, and transferring the drugs to the secure storage area.

(3) "Non-retrievable" means the condition or state to which a controlled substance shall be rendered following a process that permanently alters that controlled substance's physical or chemical condition or state through irreversible means and thereby renders the dangerous drugs which are controlled substances unavailable and unusable for all practical purposes. The process to achieve a non-retrievable condition or state may be unique to a substance's chemical or physical properties. A dangerous drug which is a controlled substance is considered non-retrievable when it cannot be transformed to a physical or chemical condition or state as a controlled substance or controlled substance analogue. The purpose of destruction is to render the controlled substance(s) to a non-retrievable state and thus prevent diversion of any such substance to illicit purposes.

(4)

(a) "Positive identification" means a method of identifying a person that does not rely on the use of a private personal identifier such as a password, but must use a secure means of identification that includes any of the following:

(i) A manual signature on a hard copy record;

(ii) A magnetic card reader;

(iii) A bar code reader;

(iv) A biometric method;

(v) A proximity badge reader;

(vi) A board approved system of randomly generated personal questions;

(vii) A printout of every transaction that is verified and manually signed within a reasonable period of time by the individual who performed the action requiring positive identification. The printout must be maintained for three years and made readily retrievable; or

(viii) Other effective methods for identifying individuals that have been approved by the board.

(b) A method relying on a magnetic card reader, a bar code reader, a proximity badge reader, or randomly generated questions for identification must also include a private personal identifier, such as a password, for entry into a secure mechanical or electronic system.

(5) "State or local correctional facility" means any of the following:

(a) A "state correctional institution," as defined in section 2967.01 of the Revised Code;

(b) A "local correctional facility," as defined in section 2903.13 of the Revised Code.

(B) A terminal distributor of dangerous drugs shall dispose of controlled substance dangerous drugs in accordance with 21 C.F.R. 1317 (9/25/2023). The method of destruction must render the controlled substances to a state of non-retrievable. Records of controlled substance destruction that are required pursuant to 21 C.F.R. 1304 (9/25/2023) shall be maintained for a minimum of three years and made readily retrievable.

(1) If a long term care facility uses a method of destruction pursuant to 21 C.F.R. 1317 (9/25/2023), the controlled substances transferred to a collection receptacle or mail-back envelope must be completed by the director of nursing and witnessed by a nurse licensed in accordance with Chapter 4723. of the Revised Code. The amount of controlled substances transferred to the receptacle or mail-back envelope and the method of disposal used must be documented with the positive identification of both individuals on the corresponding controlled substance proof-of-use sheet.

(C) If a pharmacy is servicing a long term care facility or a consultant pharmacist is employed by a long term care facility and is having a pharmacist engage in the on-site destruction of ultimate user (i.e., patient-owned) controlled substances in the custodial care of nursing staff, the pharmacy or consultant pharmacist shall have policies and procedures in place to ensure compliance with and shall comply with all the following:

(1) Upon discontinuation of a patient's use of a controlled substance medication, a nurse and director of nursing, or other pharmacy or pharmacist-approved supervisory nurse, must document the removal of the patient's medication from the medication cart or storage area and record the transfer of the drugs to a secure storage area for disposal.

(2) The record of the controlled substances removed from the medication cart, or other area of storage, for disposal shall be made on a controlled substance proof-of-use sheet. The proof-of-use sheet shall be maintained on-site at the location licensed as a terminal distributor of dangerous drugs for a minimum of three years from the date of removal and made readily retrievable.

(3) An Ohio licensed pharmacist or the director of nursing and another pharmacy or pharmacist-approved supervisory level nurse may destroy an ultimate user's controlled substances using an on-site method at the location licensed as a terminal distributor of dangerous drugs. Both individuals shall personally witness and document the destruction of the controlled substance medication pursuant to paragraph (C)(4) of this rule. The on-site method does not have to meet the definition of non-retrievable but must render the drug unavailable and unusable.

(4) A record of controlled substances destroyed shall be made containing the date of destruction, patient name, drug name, drug strength, quantity, method of destruction and the positive identification of the two individuals listed in paragraph (C)(3) of this rule responsible for the destruction.

(5) The record of controlled substance destruction pursuant to paragraph (C)(4) of this rule shall be maintained on-site at the location licensed as a terminal distributor of dangerous drugs for a minimum of three years from the date of destruction and made readily retrievable.

(6) Controlled substances shall be destroyed pursuant to this paragraph no later than ten days from the date the patient's controlled substance medication is removed from the medication cart or storage area in accordance with paragraph (C)(1) of this rule.

(D) A state or local correctional facility may engage in the on-site destruction of ultimate user (i.e., patient-owned) controlled substances in the custodial care of nursing staff, as follows:

(1) The correctional facility shall be licensed as a category III terminal distributor of dangerous drugs.

(2) The responsible person shall have policies and procedures in place to ensure compliance with and shall comply with all the following:

(a) Upon discontinuation of a patient's use of a controlled substance medication, the responsible person, director of nursing or a licensed pharmacist and another responsible person-approved nurse or corrections officer must document the removal of the patient's medication from the medication cart or storage area and record the transfer of the drugs to a secure storage area for disposal.

(b) The record of the controlled substances removed from the medication cart, or other area of storage, for disposal shall be made on a controlled substance proof-of-use sheet. The proof-of-use sheet shall be maintained on-site at the location licensed as a terminal distributor of dangerous drugs for a minimum of three years from the date of removal and made readily retrievable.

(c) The responsible person, director of nursing, or a licensed pharmacist and another responsible person-approved nurse or corrections officer may destroy ultimate user controlled substances using an on-site method at the location licensed as a terminal distributor of dangerous drugs. Both individuals shall personally witness and document the destruction of the controlled substance medication pursuant to paragraph (D)(2)(d) of this rule. The on-site method does not have to meet the definition of non-retrievable but must render the drug unavailable and unusable.

(d) A record of controlled substances destroyed shall be made containing the date of destruction, patient name, drug name, drug strength, quantity, method of destruction and the positive identification of the two individuals listed in the paragraph (D)(2)(c) of this rule responsible for the destruction. The record of controlled substance destruction shall be maintained on-site at the location licensed as a terminal distributor of dangerous drugs for a minimum of three years from the date of destruction and made readily retrievable.

(e) Controlled substances shall be destroyed no later than ten days from the date the patient's controlled substance medication is removed from the medication cart or storage area in accordance with paragraph (D)(2)(a) this rule.

(E) The unused portion of a controlled substance resulting from administration to a patient from a licensee's stock or emergency supply may be destroyed using an on-site method by any person legally authorized under Chapters 3719. and 4729. of the Revised Code and this division of the Administrative Code to possess controlled substance dangerous drugs. The on-site method does not have to meet the definition of non-retrievable but must render the drug unavailable and unusable. A record of such destruction shall be made in accordance with 21 C.F.R. 1304 (9/25/2023) and shall be maintained for a minimum of three years from the date of destruction and made readily retrievable to the board of pharmacy upon request.

Last updated July 1, 2024 at 5:25 PM

Supplemental Information

Authorized By: 3719.28, 4729.26
Amplifies: 3719.05, 3719.06, 3719.07
Five Year Review Date: 7/1/2029
Prior Effective Dates: 3/1/1999, 4/27/2007, 3/1/2019
Rule 4729:5-3-02 | Report of theft or significant loss of dangerous drugs, controlled substances, and drug documents.
 

(A) A terminal distributor of dangerous drugs shall notify the following upon discovery of the theft or significant loss of any dangerous drug or controlled substance, including drugs in transit that were either shipped from or to the licensed location:

(1) The state board of pharmacy, by telephone or other method determined by the board, immediately upon discovery of the theft or significant loss;

(2) If a controlled substance, the drug enforcement administration (DEA) pursuant to 21 C.F.R. 1301.76 (9/9/2014);

(3) Law enforcement authorities pursuant to section 2921.22 of the Revised Code.

(B) The theft or significant loss of controlled substances shall be reported by a licensee using the federal DEA report form regardless if the controlled substances are subsequently recovered and/or the responsible parties are identified and action is taken. Information reported in the federal form regarding such theft or significant loss shall be filed with the state board of pharmacy, in a manner determined by the board, by the licensee within thirty days following the discovery of such theft or significant loss.

(1) An exemption may be obtained upon sufficient cause if the federal form cannot be filed within thirty days.

(2) A request for a waiver of the thirty-day limit must be requested in a manner determined by the board.

(C) The theft or significant loss of non-controlled dangerous drugs shall be reported to the state board of pharmacy, in a manner determined by the board, by the licensee within thirty days following the discovery of such theft or significant loss of non-controlled dangerous drugs. The report shall be filed regardless if the dangerous drugs are subsequently recovered and/or the responsible parties are identified and action is taken.

(1) An exemption may be obtained upon sufficient cause if the form cannot be filed within thirty days.

(2) A request for a waiver of the thirty-day limit must be requested in a manner determined by the board.

(D) A terminal distributor of dangerous drugs shall, immediately upon discovery, notify the state board of pharmacy, in a manner determined by the board, and law enforcement authorities of any theft or loss of uncompleted prescription blank(s) used for writing a prescription, written prescription order(s) not yet dispensed and original prescription order(s) that have been dispensed.

(E) A terminal distributor of dangerous drugs shall, immediately upon discovery, notify the state board of pharmacy, in a manner determined by the board, law enforcement authorities and the drug enforcement administration (DEA) pursuant to 21 C.F.R. 1305.16 (9/9/2014) of the theft or loss of any DEA form 222.

Last updated October 31, 2021 at 12:26 AM

Supplemental Information

Authorized By: 3719.28, 4729.26
Amplifies: 3719.07, 4729.55
Five Year Review Date: 10/31/2026
Prior Effective Dates: 4/1/1978, 1/17/1997, 3/1/1999
Rule 4729:5-3-03 | Inspections and corrective actions.
 

(A) Pursuant to section 3719.13 of the Revised Code, an entity licensed by the state board of pharmacy as a terminal distributor of dangerous drugs is subject to an on-site inspection by the board. An authorized board employee may, without notice, carry out an on-site inspection or investigation of an entity licensed by the board. Upon verification of the board employee's credentials, the employee shall be permitted to enter the licensed entity.

(B) Submission of an application for a license as a terminal distributor of dangerous drugs with the state board of pharmacy constitutes permission for entry and on-site inspection by an authorized board employee.

(C) If an employee of the state board of pharmacy identifies a violation specified in paragraph (D) of this rule, the employee may provide written notice, in a manner determined by the board, of the nature of the observed violations to the responsible person on the license or application. The licensee or applicant may also be subject to disciplinary actions pursuant to Chapter 4729. of the Revised Code and this division of the Administrative Code.

(D) Violations may include any of the following:

(1) Violating any rule of the board;

(2) Violating any provision of Chapter 4729. of the Revised Code;

(3) Violating any provision of the "Federal Food, Drug, and Cosmetic Act," 52 Stat. 1040 (1938), 21 U.S.C. 301, or Chapter 3715. of the Revised Code; or

(4) Violating any provision of the federal drug abuse control laws or regulations or Chapter 2925. or 3719. of the Revised Code.

(E) The licensee or applicant shall submit to the board within thirty days of a written notice provided in accordance with paragraph (C) of this rule, in a manner determined by the board, either of the following:

(1) The action(s) the licensee or applicant has taken to correct the violation(s) and the date of implementation of the corrective action(s); or

(2) An explanation disputing the observed violations.

Last updated July 1, 2024 at 5:26 PM

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 4729.25, 3719.18, 3719.13
Five Year Review Date: 7/1/2029
Prior Effective Dates: 2/17/2017
Rule 4729:5-3-04 | Verification of licensure prior to sale or purchase.
 

(A) Before a terminal distributor of dangerous drugs may purchase dangerous drugs at wholesale, the terminal distributor shall query the board's online roster (available on the board's website: www.pharmacy.ohio.gov) to confirm any of the following:

(1) The seller is licensed to engage in the sale of dangerous drugs in accordance with section 4729.52 of the Revised Code; or

(2) The seller is licensed to engage in the occasional sale or distribution of dangerous drugs at wholesale in accordance with rule 4729:5-3-09 of the Administrative Code.

(B) If no documented query is conducted before a purchase is made, it shall be presumed that the purchase of dangerous drugs by the terminal distributor is in violation of section 4729.51 of the Revised Code.

If a licensed terminal distributor of dangerous drugs conducts a documented query at least annually and relies on the results of the query in purchasing dangerous drugs, the terminal distributor shall be deemed not to have violated section 4729.51 of the Revised Code in making the purchase.

(C) Before a terminal distributor of dangerous drugs may make a sale of dangerous drugs pursuant to rule 4729:5-3-09 of the Administrative Code, the terminal distributor shall query the board's online roster (available on the board's website: www.pharmacy.ohio.gov) to determine if the purchaser is licensed as either:

(1) A terminal distributor of dangerous drugs.

For a limited terminal distributor of dangerous drugs license, a terminal distributor shall also review a current version of the licensee's drug list to ensure the purchaser is authorized to possess the drugs ordered.

(2) A distributor of dangerous drugs in accordance with division 4729:6 of the Administrative Code.

(D) Paragraph (C) of this rule does not apply when a terminal distributor sells or distributes dangerous drugs at wholesale to any of the following:

(1) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business; or

(2) Any of the exempted persons described in section 4729.541 of the Revised Code.

(E) A terminal distributor of dangerous drugs may make a sale of a dangerous drug to any of the exempted persons described in section 4729.541 of the Revised Code in accordance with rule 4729:5-3-09 of the Administrative Code and shall ensure the purchaser meets the exemption criteria. To confirm a purchaser meets the exemption criteria, the terminal drug distributor shall comply with the all the following:

(1) Provide the purchaser, in a manner determined by the board, the requirements in Ohio law of when a purchaser shall hold a license as a terminal distributor of dangerous drugs;

(2) If the purchaser is a prescriber, verify the prescriber is appropriately licensed in this state to prescribe drugs or dangerous drugs or drug therapy related devices in the course of the individual's professional practice;

(3) Require the purchaser who claims an exemption to the terminal distributor of dangerous drug licensing requirement to annually attest in writing, which may include an electronic signature, that the purchaser meets the licensing exemptions in section 4729.541 of the Revised Code; and

(4) Ensure that all attestations are maintained by the terminal distributor for a period of three years following the date the attestation is signed by the purchaser.

Last updated August 2, 2024 at 4:57 PM

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 4729.60, 4729.37, 4729.55
Five Year Review Date: 3/1/2024
Rule 4729:5-3-05 | Confidentiality of patient records.
 

(A) Records relating to the practice of pharmacy, the administration of drugs, or any patient specific drug transaction are not a public record. A person having custody of, or access to, such records shall not divulge the contents thereof, or provide a copy thereof, to anyone except:

(1) The patient, or owner if the patient is an animal, for whom the prescription or medication order was issued.

(2) The prescriber who issued the prescription or medication order, or a subsequent treating prescriber.

(3) Licensed health care personnel who are responsible for the care of the patient.

(4) A member, inspector, agent, or investigator of the state board of pharmacy or any federal, state, county, or municipal officer whose duty is to enforce the laws of this state or the United States relating to drugs and who is engaged in a specific investigation involving a designated person or drug.

(5) An agent of an Ohio licensing agency that is responsible for the licensure or registration of a health professional authorized to prescribe drugs as defined in section 4729.01 of the Revised Code when enforcing that agency's chapter of the Revised Code.

(6) A state or federal agency charged with the responsibility of providing medical care (i.e. medicaid, medicare, workers' compensation, etc.) for the patient upon a written request by an authorized representative of the agency requesting such information.

(7) An agent of a medical insurance company who provides prescription insurance coverage to the patient upon authorization and proof of insurance by the patient or proof of payment by the insurance company for those medications whose information is requested.

(8) An agent who contracts with the terminal distributor of dangerous drugs as a "business associate" in accordance with the regulations promulgated by the secretary of the United States department of health and human services pursuant to the federal standards for privacy of individually identifiable health information.

(9) Any person, other than those listed in paragraphs (A)(1) to (A)(8) of this rule, only when the patient has given consent for such disclosure in writing. Any consent must be signed by the patient and dated. Any consent for disclosure is valid until rescinded by the patient.

In an emergency, the terminal distributor of dangerous drugs may disclose the information when, in the professional judgment of the pharmacist or healthcare provider, it is deemed to be in the best interest of the patient. A pharmacist or healthcare provider making an oral disclosure in an emergency situation must prepare a written memorandum showing the patient's name, the date and time the disclosure was made, the nature of the emergency, and the names of the individuals by whom and to whom the information was disclosed.

(B) Testimonial privilege is not waived for any communication between a prescriber, a pharmacist, and a patient pursuant to section 2317.02 of the Revised Code.

(C) Records relating to the practice of pharmacy, the administration of drugs, or any patient specific drug transaction which may be required as evidence of a violation shall be released, upon request, to a member, inspector, agent, or investigator of the state board of pharmacy or any state, county, or municipal officer whose duty is to enforce the laws of this state or the United States relating to drugs and who is engaged in a specific investigation involving a designated person or drug. Such person shall furnish a receipt to the person having legal custody of the records. If the record is a prescription, the receipt shall list the following information:

(1) Prescription identification number; or, if an order for medication, the name of the patient;

(2) The drugs prescribed or ordered;

(3) Quantity of drugs prescribed, dispensed, administered or personally furnished;

(4) Name of the prescriber;

(5) Date, name of agency, and signature of person removing the records.

(D) All such records, including consents, memoranda of emergency disclosures, and written requests pursuant to paragraph (A)(9) of this rule, shall be kept on file at the terminal distributor of dangerous drugs for a period of three years in a readily retrievable manner.

(E) All patient records maintained by a terminal distributor of dangerous drugs shall be maintained in accordance with the following:

(1) For human patients, the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and

(2) All state and federal laws, rules, and regulations.

Last updated July 1, 2024 at 5:26 PM

Supplemental Information

Authorized By: 3719.28, 4729.26
Amplifies: 3719.05, 3719.07, 3719.13, 3719.27, 4729.27, 4729.37, 4729.39
Five Year Review Date: 7/1/2029
Prior Effective Dates: 3/19/1987
Rule 4729:5-3-06 | Storage of adulterated drugs.
 

To prevent their use, adulterated drugs, as defined in agency 4729 of the Administrative Code, shall be stored in a separate and secure area apart from the storage of drugs used for dispensing, personally furnishing, compounding, and administration.

(A) Adulterated drugs shall be stored no longer than one year from the date of adulteration or expiration by those holding a terminal distributor of dangerous drugs license. Adulterated drugs shall be stored in a manner that prohibits access by unauthorized persons.

(B) Dangerous drugs, other than controlled substances, may be destroyed utilizing proper methods of disposal and following the record keeping requirements noted in agency 4729 of the Administrative Code, or may be donated to a pharmacy school pursuant to sections 3715.88 to 3715.92 of the Revised Code. Methods of disposal of non-controlled dangerous drugs shall prevent the possession or use of the drugs by unauthorized persons.

(C) Dangerous drugs that are controlled substances shall be disposed of pursuant to rule 4729:5-3-01 of the Administrative Code.

Last updated July 1, 2024 at 5:27 PM

Supplemental Information

Authorized By: 3719.28, 4729.26, 3715.91
Amplifies: 3715.88, 3715.89, 3715.90, 3715.92, 3719.05, 3719.06, 4729.53, 4729.55
Five Year Review Date: 7/1/2029
Prior Effective Dates: 7/1/1993
Rule 4729:5-3-07 | Controlled substances inventory requirements.
 

(A) Unless otherwise stated in this division of the Administrative Code, all category III terminal distributor licensees shall complete a controlled substances inventory in accordance with 21 CFR 1304.11 (9/9/2014).

(B) All controlled substance inventories performed in accordance with this rule shall be conducted on an annual basis. The annual inventory may be taken on any date which is within thirteen months of the previous inventory date.

(C) The terminal distributor's responsible person shall be responsible for completing and maintaining this inventory record at the location licensed as a terminal distributor of dangerous drugs.

(D) All inventory records shall be maintained for a period of three years from the completion date of the inventory and made readily retrievable.

(E) When a drug or compound is added to the schedule of controlled substances by state or federal law, rule or regulation, a terminal distributor shall complete an inventory pursuant to this rule of all stocks of such drug or compound no later than ten days of the drug or compound being added to the schedule.

(F) In the event a terminal distributor of dangerous drugs commences business with no controlled substances on hand, this fact shall be recorded as the initial inventory.

Last updated April 15, 2024 at 1:33 PM

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 4729.54, 4729.55
Five Year Review Date: 3/18/2029
Rule 4729:5-3-08 | Sales of dangerous drugs on-line.
 

(A) All persons selling or offering to sell dangerous drugs via the internet at retail, into, out of, or within Ohio must be properly licensed with the state board of pharmacy.

(B) All terminal distributors of dangerous drugs who sell or offer to sell dangerous drugs at retail on the internet to persons located in Ohio or any other state must make such sales only in compliance with all state and federal laws, rules, and regulations governing the legal distribution of dangerous drugs.

(C) Except as provided in paragraph (F) of this rule, all terminal distributors of dangerous drugs who sell or offer to sell dangerous drugs at retail on the internet to persons located in Ohio shall maintain a digital pharmacy accreditation from the national association of boards of pharmacy, as approved by the board.

(D) Websites owned and/or maintained by a terminal distributor of dangerous drugs who sell or offer to sell dangerous drugs at retail on the internet to persons located in Ohio or any other state must provide the following information to the public:

(1) Name under which the terminal distributor is licensed to do business as in Ohio.

(2) Full address of the licensed location.

(3) Telephone number where the terminal distributor may be contacted during regular business hours.

(4) A list of the states in which the terminal distributor may legally sell dangerous drugs.

(5) The name, address, and how the state licensing agency and the drug enforcement administration may be contacted in each state in which the person is authorized to do business. This may include a link to the agency's and the drug enforcement administration's website.

(E) Any Ohio licensed terminal distributor requesting personal information from the public by way of the internet (e.g., questionnaire forms, e-mail, etc.) must provide for security and confidentiality of the information. This portion of the website must also provide information regarding how the personal information will be used, pursuant to all federal and state laws, rules, and regulations, and ensure that such information is not used for purposes not disclosed without the written informed consent of the patient or person submitting personal information.

(F) A veterinarian, licensed under Chapter 4741. of the Revised Code, may sell or offer to sell dangerous drugs via the internet only when the internet pharmacy that fulfills the dangerous drug prescription or facilitates the sale of the dangerous drug maintains a digital pharmacy accreditation from the national association of boards of pharmacy.

Last updated July 1, 2024 at 5:27 PM

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 4729.54, 4729.55
Five Year Review Date: 7/1/2029
Rule 4729:5-3-09 | Occasional sale and drug transfers.
 

(A) The term "occasional sale" as used in section 4729.51 of the Revised Code means a wholesale sale of a commercially manufactured dangerous drug to a person licensed in accordance with section 4729.52 of the Revised Code, terminal distributor of dangerous drugs or any entity or person exempted from licensure as a terminal distributor of dangerous drugs by any of the following:

(1) A pharmacy licensed as a terminal distributor of dangerous drugs;

(2) A licensed terminal distributor of dangerous drugs that is not a pharmacy, but only as authorized in section 4729.51 of the Revised Code;

(3) A local health department, as defined in paragraph (H) of this rule, licensed as a terminal distributor of dangerous drugs for the purpose of improving or promoting public health within the department's jurisdiction, but only for the sale of non-controlled dangerous drugs; or

(4) A drug repository program pursuant to rule 4729:5-10-07 of the Administrative Code.

(B) The dosage units of all dangerous drugs distributed by the pharmacy pursuant to this rule shall not exceed five per cent of the total dosage units dispensed by the pharmacy during the same calendar year.

(C) The limits set forth in this rule do not apply to the following:

(1) A licensed terminal distributor of dangerous drugs as described in paragraph (A)(2) of this rule;

(2) Pharmacies that are also licensed to conduct sales of dangerous drugs in accordance with section 4729.52 of the Revised Code; and

(3) Drug repository programs pursuant to rule 4729:5-10-07 of the Administrative Code.

(D) The requirements of this rule do not apply to the transfer of dangerous drugs pursuant to paragraph (E) of this rule.

(E) A licensed terminal distributor of dangerous drugs having more than one licensed location may transfer or deliver dangerous drugs from one licensed location to another licensed location owned by that terminal distributor if the license issued for each location is in effect at the time of the transfer or delivery. Such transfer or delivery includes either of the following:

(1) Intracompany sales, which includes any transaction or transfer between any division, subsidiary, parent or affiliated or related company under the common ownership and control.

(2) The sale, purchase, or transfer of a drug or an offer to sell, purchase, or transfer of a drug among hospitals or other health care entities that are under common control. Common control means the power to direct or cause the direction of the management and policies of a person or an organization, whether by ownership of stock, voting rights, by contract, or otherwise.

(F) Occasional sales by a licensed terminal distributor shall comply with the reporting requirements set forth in division 4729:8 of the Administrative Code.

(G) "Drug shortage," with respect to an occasional sale, means a drug on the United States food and drug administration's drug shortage list that is not commercially available regardless of the reason that the drug is not available, including the absence of a manufacturer for the drug or the lack of a readily available supply of the drug from a manufacturer or wholesaler.

(H) "Local health department' means a department operated by a board of health of a city or general health district or the authority having the duties of a board of health as described in section 3709.05 of the Revised Code.

Last updated May 30, 2023 at 8:26 AM

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 4729.51, 4729.541
Five Year Review Date: 8/28/2024
Rule 4729:5-3-10 | Employment of individuals with felony convictions.
 

(A) Pursuant to 21 C.F.R. 1301.76 (6/22/2023), a terminal distributor of dangerous drugs that is a United States drug enforcement administration registrant shall not employ in a position which allows access to controlled substances any person who has been convicted of a felony relating to controlled substances, or who, at any time, has had an application for drug enforcement administration registration denied, revoked, or surrendered for cause.

"For cause" means surrendering a registration in lieu of, or as a consequence of, any federal or state administrative, civil, or criminal action resulting from an investigation of the individual's handling of controlled substances.

(B) Paragraph (A) of this rule does not apply if a waiver is obtained by a licensee pursuant to 21 C.F.R. 1307.03 (3/9/2010).

Last updated July 1, 2024 at 5:28 PM

Supplemental Information

Authorized By: 3719.28, 4729.26
Amplifies: 4729.54, 4729.55
Five Year Review Date: 7/1/2029
Prior Effective Dates: 3/1/2019
Rule 4729:5-3-11 | Transmission of outpatient prescriptions.
 

(A) Oral transmission by a prescriber or a prescriber's agent of an original outpatient prescription authorized by a prescriber shall comply with the requirements of rule 4729:5-5-15 of the Administrative Code. For any oral outpatient prescription transmitted by an agent of a prescriber, the prescriber's agent must provide the agent's first and last name when transmitting the prescription. An oral prescription may be transmitted by a prescriber or prescriber's agent to a recording device or voice mail service.

(B) Original written outpatient prescriptions shall be authorized and signed by a prescriber, in the same manner as the prescriber would sign a check or legal document, and may be transmitted by the prescriber or the prescriber's agent by facsimile machine to a pharmacy.

(1) The facsimile of the prescription must include the identification number of the facsimile machine which is used to transmit the prescription, the full name of the prescriber and, if applicable, the full name of the prescriber's agent transmitting the prescription to the pharmacy.

(2) The prescription must comply with the requirements of rule 4729:5-5-15 of the Administrative Code.

(3) The original prescription signed by the prescriber from which the facsimile is produced shall not be issued to the patient. The original prescription signed by the prescriber must remain with the patient's records at the location where it was issued for three years from the date of issuance. Following the successful transmission of the prescription, the word "VOID" or "FAXED" shall be written or stamped on the face of the original prescription in a manner that does not destroy any of the original information contained on the prescription.

(4) Outpatient prescriptions for schedule II controlled substances may be transmitted by facsimile in accordance with 21 C.F.R. 1306.11 (5/1/2019) and shall meet the facsimile requirements of this rule.

(C) Outpatient prescriptions may be transmitted by means of an electronic prescription transmission system that complies with the prescription requirements in rule 4729:5-5-15 of the Administrative Code.

(1) An outpatient prescription transmitted by means of an electronic prescription transmission system shall include the full name of the prescriber's agent transmitting the prescription.

(2) A controlled substance outpatient prescription shall only be transmitted by means of an electronic prescription transmission system if the system complies with 21 CFR 1311 (5/1/2019).

(3) Except as provided in paragraphs (C)(4) and (C)(5) of this rule, no prescriptions may be transmitted by means of an electronic prescription transmission system that converts the prescription into a computer-generated fax or scanned image.

(4) A non-controlled prescription may be transmitted by means of an electronic prescription transmission system that converts the prescription into a computer-generated fax or scanned image if all the following apply:

(a) The transmission is conducted by means of a board approved system that meets the prescription requirements of rule 4729:5-5-15 of the Administrative Code.

(b) The prescription transmission system operates within a closed-system. A closed system includes any system whereby prescription information is transmitted directly between:

(i) Any division, subsidiary, parent or affiliated or related company under common ownership and control; or

(ii) One or more contracted entities. Contracted means having a written agreement (to include business associate agreements) between one or more prescribers and a pharmacy and shall not include a third-party intermediary unless otherwise approved by the board.

(5) A non-controlled prescription may be converted into a computer-generated fax by a board approved third-party intermediary only if the conversion is necessitated by a temporary telecommunication outage of the third-party intermediary or receiving pharmacy.

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 3719.05, 4729.38, 4729.39, 4729.37, 4729.281, 4729.01, 3719.06
Five Year Review Date: 12/1/2025
Rule 4729:5-3-12 | Protocols and pre-printed orders for medication administration.
 

(A) A terminal distributor of dangerous drugs may distribute or dispense dangerous drugs pursuant to a protocol. As used in this rule, "protocol" means a definitive set of written treatment guidelines with orders for drugs and their specified dosages for administration to individuals under the following circumstances:

(1) The provision of medical services to individuals in an emergency situation when the services of a prescriber authorized by the revised code to prescribe dangerous drugs as part of their professional practice are not immediately available. An emergency situation may manifest itself by acute symptoms of sufficient severity that an authorized individual providing medical services under this paragraph could reasonably expect the absence of immediate medical attention to result in placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. Examples of emergency situations includes cases such as heart attacks, severe burns, extravasation, overdoses, cyanide poisonings, electrocutions, or severe asthmatic attacks;

(2) The administration of biologicals or vaccines to individuals for the purpose of preventing diseases;

(3) The administration of vitamin K for prevention of vitamin K deficient bleeding in newborns;

(4) The administration of erythromycin for prevention of ophthalmia neonatorum; and

(5) The administration of influenza antiviral treatment and chemoprophylaxis to residents and health care personnel at an institutional facility, as defined in agency 4729 of the Administrative Code, according to current guidance issued by the United States center for disease control and prevention.

(B) A protocol described in paragraph (A) of this rule shall:

(1) Include a description of the intended recipients to whom the drugs are to be administered; drug name and strength; instructions of how to administer the drug, dosage, and frequency; signature of a prescriber or some other form of positive identification of the prescriber as defined in agency 4729 of the Administrative Code; and date of signature;

(2) Be administered by an individual authorized by law to administer the drugs;

(3) Be made readily retrievable;

(4) Be reviewed as necessary to ensure patient safety and practice in accordance with acceptable and prevailing standards of care; and

(5) Be maintained by the terminal distributor of dangerous drugs for a period of three years from the date of authorization or reauthorization following any modification or amendment.

(C) A terminal distributor of dangerous drugs may distribute or dispense dangerous drugs for administration pursuant to a pre-printed order. As used in this rule, "pre-printed order" means a patient specific and dose specific order for the administration of a specific drug or drugs prescribed by a licensed health care professional authorized to prescribe drugs. The prescriber must complete an assessment and make a diagnosis prior to initiating a pre-printed order in accordance with the prescriber's scope of practice. The pre-printed order may only be initiated upon the order of a prescriber authorized by law to prescribe the drugs listed in the pre-printed orders. The drugs shall be administered by an individual authorized by law to administer the drugs.

(D) A pre-printed order described in paragraph (C) of this rule shall:

(1) Include the name of the patient; drug name and strength; specific instructions of how to administer the drug, dosage, and frequency; instructions of any patient specified dosage range based on objective measures such as calculations and patient physiologic data; signature of the prescriber or some other form of positive identification of the prescriber as defined in agency 4729 of the Administrative Code; and date of signature;

(2) Apply only to those drugs for which the therapeutic dose is significantly lower than the dose expected to cause detrimental adverse effects;

(3) Can be performed without requiring the exercise of medical judgment;

(4) Will lead to results that are reasonably predictable and safe;

(5) Can be performed safely by the individual authorized to administer the drugs and without the need for repeated medical assessments;

(6) Be maintained by the terminal distributor of dangerous drugs for a period of three years from the date of initiation. A pre-printed order which becomes a permanent part of the patient's medical record shall be deemed to meet the requirements of this paragraph;

(7) Be made readily retrievable;

(8) If performed improperly, would not present a danger of immediate and serious harm to the patient; and

(9) Be reviewed as necessary to ensure patient safety and practice in accordance with acceptable and prevailing standards of care.

(E) Nothing in this rule shall be construed to otherwise prohibit the dispensing or administration of dangerous drugs pursuant to a protocol that is specifically authorized in the Revised Code or agency 4729 of the Administrative Code.

(F) For purposes of this rule, a terminal distributor of dangerous drugs may distribute or dispense dangerous drugs for administration to animals pursuant to a protocol in accordance with the provisions of paragraphs (A) and (B) of this rule or a pre-printed order in accordance with the provisions of paragraphs (C) and (D) of this rule.

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 3719.01, 4729.01, 4729.54, 4729.55, 4729.57
Five Year Review Date: 3/1/2025
Prior Effective Dates: 9/10/1976, 7/1/1992, 1/17/1997, 1/1/2004
Rule 4729:5-3-13 | Temporary removal of dangerous drugs from a licensed location.
 

No licensed terminal distributor of dangerous drugs shall engage in the sale or other distribution of dangerous drugs at retail or maintain possession, custody, or control of dangerous drugs for any purpose at any establishment or place other than that or those described in the license issued by the state board of pharmacy to such terminal distributor, except as follows:

(A) A licensed health professional authorized to prescribe drugs may temporarily remove dangerous drugs from a licensed terminal distributor of dangerous drugs in order to treat current or prospective patients. The dangerous drugs shall be returned to the licensed terminal distributor of dangerous drugs within twenty-four hours, unless otherwise approved by the board. The licensed health professional shall maintain direct supervision and control over the dangerous drugs and any hypodermics removed from the terminal distributor. If direct supervision is not provided, the dangerous drugs and any hypodermics shall be physically secured in a manner to prevent unauthorized access and shall be stored at temperatures and conditions which will ensure the integrity of the drugs prior to their use as stipulated by the USP/NF and/or the manufacturer's or distributor's labeling. The responsible person on the terminal distributor of dangerous drugs license shall be responsible for compliance with the requirements of this paragraph.

(B) A person authorized to personally furnish or dispense naloxone in accordance with a physician approved protocol. The naloxone shall be returned to the licensed terminal distributor of dangerous drugs within twenty-four hours, unless otherwise approved by the board. The authorized person shall maintain direct supervision and control over the naloxone removed from the terminal distributor. If direct supervision is not provided, the naloxone shall be physically secured in a manner to prevent unauthorized access and shall be stored at temperatures and conditions which will ensure the integrity of the drugs prior to their use as stipulated by the USP/NF and/or the manufacturer's or distributor's labeling. The responsible person on the terminal distributor of dangerous drugs license shall be responsible for compliance with the requirements of this paragraph.

(C) A licensed health care professional, in accordance with their applicable scope of practice, who provides immunizations or any other non-controlled substance dangerous drugs that may be administered in accordance with a protocol or valid prescriber's order may temporarily remove dangerous drugs from a licensed terminal distributor of dangerous drugs in order to treat current or prospective patients. The dangerous drugs shall be returned to the licensed terminal distributor of dangerous drugs within twenty-four hours, unless otherwise approved by the board. The licensed health professional shall maintain direct supervision and control over the dangerous drugs and any hypodermics removed from the terminal distributor. If direct supervision is not provided, the dangerous drugs and any hypodermics shall be physically secured in a manner to prevent unauthorized access and shall be stored at temperatures and conditions which will ensure the integrity of the drugs prior to their use as stipulated by the USP/NF and/or the manufacturer's or distributor's labeling. The responsible person on the terminal distributor of dangerous drugs license shall be responsible for compliance with the requirements of this paragraph.

(D) An emergency medical service (EMS) organization providing emergency medical services and in accordance with Chapter 4729:5-14 of the Administrative Code.

(E) A veterinarian licensed pursuant to Chapter 4741. of the Revised Code may maintain a supply of dangerous drugs obtained from a licensed terminal distributor of dangerous drugs at another location in order to treat current or prospective patients. A veterinarian shall maintain direct supervision and control over the dangerous drugs and any hypodermics removed from the terminal distributor. If direct supervision is not provided, the dangerous drugs and any hypodermics shall be physically secured in a manner to prevent unauthorized access and all reasonable efforts shall be made to store the drugs at temperatures and conditions which will ensure the integrity of the drugs prior to their use as stipulated by the USP/NF and/or the manufacturer's or distributor's labeling. Any drugs maintained pursuant to this paragraph are subject to inspection by a board of pharmacy agent and shall be subject to all recordkeeping, labeling, theft or significant loss reporting, disposal, and inventory requirements of division 4729:5 of the Administrative Code. Records shall be maintained by the terminal distributor of dangerous drugs in accordance with Chapter 4729:5-20 of the Administrative Code. The responsible person on the terminal distributor of dangerous drugs license from which the drugs are obtained shall be responsible for compliance with the requirements of this paragraph. A veterinarian maintaining dangerous drugs in accordance with this rule shall only obtain the drugs from single terminal distributor and shall not co-mingle drug stock from another terminal distributor of dangerous drugs. The terminal distributor of dangerous drugs shall also maintain the following records for controlled substance dangerous drugs removed from the terminal distributor of dangerous drugs that are stored off-site for more than twenty-four hours: name, strength, dosage form, and quantity of the controlled substance dangerous drugs, the positive identification of the veterinarian who removed the drugs, and the address of the location where the drugs are maintained. Corresponding records shall also be maintained for any controlled substances returned to the terminal distributor's inventory of dangerous drugs from the off-site location. All records required in accordance with this paragraph shall be readily retrievable and maintained for at least three years from the date of removal or return. Failure by a veterinarian to exercise supervision and control of dangerous drugs as required in division (B) of section 4729.55 of the Revised Code or adequate safeguards as required in division (C) of section 4729.55 of the Revised Code shall be deemed a violation of this rule.

(F) A person licensed or certified under Chapter 4765. of the Revised Code may maintain a supply of medical oxygen and/or naloxone obtained from a licensed terminal distributor of dangerous drugs in order to treat current or prospective patients in the event of an emergency. The medical oxygen and/or naloxone shall be maintained for an amount of time as determined by written authorization from the licensee's medical director. Medical oxygen and naloxone shall only be administered in accordance with the licensee's protocol or valid prescriber order. The individuals authorized by to this paragraph shall maintain personal supervision and control over the medical oxygen and/or naloxone removed from the terminal distributor. If personal supervision is not provided, the medical oxygen and/or naloxone shall be physically secured in a manner to prevent unauthorized access and shall be stored at temperatures and conditions which will ensure the integrity of the medical oxygen and/or naloxone prior to its use as stipulated by the USP/NF and/or the manufacturer's or distributor's labeling.

(G) A certified officer, as defined in section 4729.533 of the Revised Code, may maintain a supply of dangerous drugs, as authorized in rule 4729:5-15-05 of the Administrative Code, obtained from a licensed terminal distributor of dangerous drugs with a chemical capture classification at another location in order to engage in chemical capture. A certified officer shall maintain direct supervision and control over the dangerous drugs, equipment, and any hypodermics removed from the terminal distributor. If direct supervision is not provided, the dangerous drugs, equipment, and any hypodermics shall be physically secured in a manner to prevent unauthorized access and all reasonable efforts shall be made to store the drugs at temperatures and conditions which will ensure the integrity of the drugs prior to their use as stipulated by the USP/NF and/or the manufacturer's or distributor's labeling. Any drugs maintained pursuant to this paragraph are subject to inspection by a board of pharmacy agent and shall be subject to all recordkeeping, labeling, theft or significant loss reporting, disposal, and inventory requirements of division 4729:5 of the Administrative Code. Records shall be maintained by the terminal distributor of dangerous drugs in accordance with Chapter 4729:5-15 of the Administrative Code. The responsible person on the terminal distributor of dangerous drugs license from which the drugs are obtained shall be responsible for compliance with the requirements of this paragraph. A certified officer maintaining dangerous drugs in accordance with this rule shall only obtain the drugs from single terminal distributor and shall not co-mingle drug stock from another terminal distributor of dangerous drugs. The terminal distributor of dangerous drugs shall also maintain the following records for controlled substance dangerous drugs removed from the terminal distributor of dangerous drugs that are stored off-site: name, strength, dosage form, and quantity of the controlled substance dangerous drugs, the positive identification of the certified officer who removed the drugs, and the address of the location where the drugs are maintained. Corresponding records shall also be maintained for any controlled substances returned to the terminal distributor's inventory of dangerous drugs from the off-site location. All records required in accordance with this paragraph shall be readily retrievable and maintained for at least three years from the date of removal or return. Failure by a certified officer to exercise supervision and control of dangerous drugs as required in division (B) of section 4729.55 of the Revised Code or adequate safeguards as required in division (C) of section 4729.55 of the Revised Code shall be deemed a violation of this rule.

(H) An opioid treatment program operating a mobile opioid treatment program in accordance with rule 4729:5-21-05 of the Administrative Code.

(I) As used in this rule, "direct supervision" means an individual authorized pursuant to this rule is in the immediate area and within visual range of dangerous drugs and/or hypodermics to deter and detect diversion.

Last updated December 27, 2021 at 5:43 PM

Supplemental Information

Authorized By: 3719.28, 4729.26
Amplifies: 3719.05, 3719.09, 3719.172, 4729.27, 4729.28, 4729.51, 4729.531, 4729.532, 4729.55, 4729.57
Five Year Review Date: 12/26/2026
Prior Effective Dates: 9/10/1976, 2/1/1998, 9/15/2017
Rule 4729:5-3-14 | General security requirements.
 

(A) All terminal distributors of dangerous drugs shall provide effective controls and procedures to:

(1) Deter and detect the theft and diversion of dangerous drugs; and

(2) Ensure supervision and control of dangerous drugs, as required in division (B) of section 4729.55 of the Revised Code, and adequate safeguards to ensure that dangerous drugs are being distributed in accordance with all state and federal laws, as required in section 4729.55 of the Revised Code.

(B) Substantial compliance with the standards set forth in this division of the Administrative Code may be deemed sufficient by the state board of pharmacy after evaluation of the overall security system and needs of the licensee or applicant. In evaluating the overall security system of a licensee or applicant, the state board of pharmacy may consider any of the following factors, as deemed relevant, for compliance with security requirements:

(1) The type of activity conducted;

(2) Type and form of dangerous drugs handled;

(3) Quantity of dangerous drugs handled;

(4) Location of the premises and the relationship such location bears on security needs;

(5) Type of building construction comprising the facility and the general characteristics of the building or buildings;

(6) Type of vaults, safes, and secure enclosures or other storage system (e.g. automatic storage and retrieval system) used;

(7) Type of closures on vaults, safes, and secure enclosures;

(8) Adequacy of key control systems and/or combination lock control systems;

(9) Adequacy of electronic detection and alarm systems, if any, including use of supervised transmittal lines and standby power sources;

(10) Extent of unsupervised public access to the facility, including the presence and characteristics of perimeter fencing, if any;

(11) Adequacy of supervision over authorized employees having access to areas containing dangerous drugs;

(12) Procedures for handling business guests, visitors, maintenance personnel, and non-employee service personnel; and

(13) Adequacy of the licensee's or applicant's system for monitoring the receipt, manufacture, distribution, and disposition of dangerous drugs in its operation.

(C) When physical security controls become inadequate as a result of a significant increase in the quantity of dangerous drugs in the possession of the licensee during normal business operation, the physical security controls shall be expanded and extended accordingly.

(D) Any applicant seeking to determine whether a proposed security system substantially complies with, or is the structural equivalent of, the requirements set forth in this division of the Administrative Code may submit any plans, blueprints, sketches, or other materials regarding the proposed security system to the state board of pharmacy.

Supplemental Information

Authorized By: 3719.28, 4729.26
Amplifies: 3719.05, 3719.09, 3719.172, 4729.27, 4729.28, 4729.51, 4729.531, 4729.55, 4729.57
Five Year Review Date: 3/1/2025
Prior Effective Dates: 9/15/2017
Rule 4729:5-3-15 | Use of hospital and other institution D.E.A. registrations.
 

(A) As used in this rule, "hospital or other institution" has the same meaning as in Part 1301 of the Code of Federal Regulations.

(B) A prescriber who is an agent or employee of a hospital or other institution may, when acting in the normal course of business or employment, administer, personally furnish, or prescribe controlled substances under the "Drug Enforcement Administration" (D.E.A.) registration of the hospital.

(C) A person pursuing an approved training program within the jurisdiction of the hospital or other institution and authorized to write prescriptions pursuant to paragraph (B) of rule 4729:5-1-02 of the Administrative Code may administer, personally furnish, or prescribe controlled substances under the registration of the hospital or other institution. Persons pursuing such approved training programs may function in sites outside the physical confines of the hospital or other institution only if such sites are part of the training program and the persons are under the employment and jurisdiction of the hospital or other institution administering the approved program. While functioning in the outside sites, such persons may continue to use the internal code assigned by the hospital or other institution administering the approved program, upon mutual agreement of the hospital or other institution and the outside site.

(D) The administering, personally furnishing, or prescribing must be done in the usual course of the person's professional practice and only within the scope of the person's employment in the hospital or other institution.

(E) Each person so authorized must be assigned a specific internal code number by the hospital or other institution which will be used as a suffix to the hospital D.E.A. registration number. Such internal code number shall consist of numbers, letters, or a combination thereof, shall be preceded by a hyphen, and no more than ten characters in length, excluding the hyphen. A current list of the internal codes and the corresponding individual prescribers must be kept by the hospital or other institution and made available at all times to other registrants, state board of pharmacy designated agents, investigators of the state medical board, and federal, state, county, or municipal law enforcement agencies for verification.

A current list of internal codes and the corresponding individual prescribers shall be filed with the state board of pharmacy, in a manner and format determined by the board. Additions, deletions or changes to the list must be submitted to the state board of pharmacy within ten business days of any such addition, deletion or change.

(F) A pharmacist practicing under a consult agreement, as authorized in section 4729.39 of the Revised Code, shall not prescribe controlled substances under the registration of the hospital or other institution.

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 3715.63, 3719.05
Five Year Review Date: 12/1/2025
Prior Effective Dates: 7/1/1991, 11/25/1994, 3/1/1999
Rule 4729:5-3-16 | Returned drugs.
 

(A) No drug that has been dispensed pursuant to a prescription or personally furnished by a prescriber and has left the physical premises of the terminal distributor of dangerous drugs shall be returned to the terminal distributor or dispensed or personally furnished again, except as follows:

(1) Drugs dispensed for inpatients, as defined in agency 4729 of the Administrative Code, or personally furnished to inpatients provided that:

(a) The drugs are packaged in unopened, single-dose or tamper-evident containers; and

(b) The drugs have not been in the possession of the ultimate user.

(2) Drugs dispensed for inpatients, as defined in agency 4729 of the Administrative Code, in accordance with rule 4729:5-9-02.11 of the Administrative Code.

(3) Drugs dispensed for outpatients in accordance with rules 4729:5-5-22 and 4729:5-5-18 of the Administrative Code.

(4) Drugs dispensed for patients, which have not been dispensed or personally furnished directly to the ultimate user, that require further manipulation prior to administration.

(5) Drugs donated to a drug repository program in accordance with Chapter 4729:5-10 of the Administrative Code.

(6) Drugs returned for destruction or disposal in accordance with division 4729:10 of the Administrative Code and rule 4729:5-5-14 of the Administrative Code.

(7) Hazardous drugs for destruction or disposal in accordance with all applicable federal, state, and local laws, rules, and regulations.

(B) As used in this rule, "hazardous drug" means any drug listed on the national institute for occupational safety and health's list of antineoplastic and other hazardous drugs in healthcare settings as referenced in rule 4729:7-1-01 of the Administrative Code.

(C) Except as provided in section 4729.43 of the Revised Code, nothing in this rule prohibits a terminal distributor of dangerous drugs from administering a dangerous drug that was dispensed or personally furnished directly to a patient or patient's caregiver.

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 3715.63, 3719.05
Five Year Review Date: 3/9/2025
Rule 4729:5-3-17 | Automated pharmacy systems.
 

(A) As used in this rule:

(1) "Automated pharmacy system" means a mechanical system that performs operations or activities, other than administration, relative to storage, packaging, compounding, dispensing, or distribution of dangerous drugs that collects, controls, and maintains transaction information and records.

"Automated pharmacy system" does not include an "automated drug storage system" utilized by institutional facilities pursuant to Chapter 4729:5-9 of the Administrative Code or other locations licensed as terminal distributors of dangerous drugs.

(2) "Dispense" means the final association of a drug with a particular patient pursuant to a prescription, drug order, or other lawful order of a prescriber and the professional judgment of and the responsibility for interpreting, preparing, compounding, labeling, and packaging a specific drug.

(a) In the case of an automated pharmacy system that dispenses dangerous drugs without the final association by a pharmacist, the system shall capture the positive identification of the pharmacist authorizing the patient specific prescription in the system prior to its dispensation.

(b) Nothing in this paragraph shall prohibit an automated pharmacy system from being utilized to restock an automated drug storage system utilized by institutional facilities pursuant to Chapter 4729:5-9 of the Administrative Code or other locations licensed as terminal distributors of dangerous drugs.

(3) "Positive identification" has the same meaning as in rule 4729:5-5-01 of the Administrative Code.

(4) "Tamper evident" means a package, storage container or other physical barrier that is sealed or secured in such a way that access to the drugs stored within is not possible without leaving visible proof that such access has been attempted or made.

(B) An automated pharmacy system shall be approved by the board prior to its implementation by the terminal distributor of dangerous drugs.

(1) Prior to the approval of an automated pharmacy system, the board shall receive a request from the responsible person on the terminal distributor of dangerous drugs license. Upon notification, the board shall conduct an inspection of the system to determine if it meets the requirements of this rule.

(2) For automated pharmacy systems that dispense dangerous drugs in accordance with paragraph (A)(2)(a) of this rule, the responsible person of the licensed terminal distributor of dangerous drugs shall be required to have a pharmacist verify for accuracy all dangerous drugs dispensed by the system for a continuous forty-five-day period. The responsible person shall compile metrics, using a form developed by the board, documenting the performance of the system during this period. Unless otherwise approved by the board, the accuracy metrics during the forty-five day pharmacy review period shall be no less than ninety-nine and nine hundred eighty-five thousandths (99.985) per cent.

(3) Approval of all automated pharmacy systems shall be site-specific.

(C) An automated pharmacy system shall be located on the premises of a licensed terminal distributor of dangerous drugs.

(D) A terminal distributor of dangerous drugs operating an automated pharmacy system shall maintain the following documentation on-site in a readily retrievable manner:

(1) The manufacturer's name and model;

(2) A description of how the automated pharmacy system is used; and

(3) Policies and procedures for system operation, safety, security, accuracy, patient confidentiality, access, and malfunction.

(E) All records maintained in accordance with this rule, including documentation of quality assurance metrics, shall be readily retrievable and maintained for period of three years.

(F) For automated pharmacy systems that dispense dangerous drugs in accordance with paragraph (A)(2)(a) of this rule, the terminal distributor of dangerous drugs shall implement a quality assurance program to determine continued appropriate use of the automated pharmacy system. The quality assurance program shall monitor the performance of the automated pharmacy system, ensure the system is in good working order and accurately prepares the correct strength, dosage form, and quantity of the drug prescribed or ordered. At a minimum, the quality assurance program shall consist of a review of at least five per cent of all dispensed prescriptions over the daily operational hours of the automated pharmacy system.

(G) If an automated pharmacy system that dispenses dangerous drugs in accordance with paragraph (A)(2)(a) of this rule selects an incorrect drug, the terminal distributor shall immediately institute a one hundred per cent pharmacist verification of all drugs dispensed. The one hundred per cent verification procedure shall continue until such time as the terminal distributor can document that the cause of the error has been determined and addressed and that the system is no longer making errors.

(H) A registered or certified pharmacy technician, pharmacy technician trainee, pharmacy intern, or nurse licensed in accordance with Chapter 4723. of the Revised Code may stock an automated pharmacy system provided that:

(1) Except as provided in paragraph (H)(2) of this rule, the container, canister, or other dangerous drug storage device being stocked by the technician, trainee, intern, or nurse is tamper-evident and is verified by a pharmacist and documented using positive identification.

(2) Pharmacist verification requirements in paragraph (H)(1) of this rule do not apply if all the following are met:

(a) Verification is being conducted by a registered or certified pharmacy technician, pharmacy intern, or nurse; and

(b) The container, canister, or other dangerous drug storage device being stocked is properly identified by bar code or other such secondary information system, which has been verified by a pharmacist to ensure the proper drug is being placed into and recognized as the correct drug by the system.

(3) The utilization of a bar code, electronic verification, or similar verification process shall require an initial quality assurance validation by a pharmacist and shall be followed by a quarterly quality assurance review by a pharmacist.

(4) The positive identification of the individual stocking the system is documented.

(5) A pharmacist is fully responsible for all activities conducted by the technician, trainee, intern, or nurse.

(6) A pharmacist must be immediately available to answer questions or discuss the stocking of an automated pharmacy system.

(7) A registered pharmacy technician or pharmacy technician trainee shall be acting under the personal supervision of a pharmacist.

(I) Except for an automated pharmacy system in a long-term care facility, a pharmacist shall be physically present at the terminal distributor of dangerous drugs to provide supervision of the automated pharmacy system.

(J) The automated pharmacy system shall have security to prevent unauthorized individuals from accessing or obtaining dangerous drugs and include safeguards to detect the diversion of dangerous drugs. This shall include the use of tamper-evident containers, canisters, or other storage devices for use in long-term care facilities.

(K) The records kept by the automated pharmacy system shall comply with the applicable record keeping requirements of division 4729:5 of the Administrative Code and shall also capture all events involving the contents of the automated pharmacy system.

(L) If applicable, an automated pharmacy system shall comply with the requirements set forth in 21 CFR 1301.27 (5/13/2005) for automated systems in long term care facilities.

Last updated June 4, 2021 at 8:24 AM

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 3719.05, 3719.07, 3719.09, 4729.28, 4729.37, 4729.51
Five Year Review Date: 6/4/2026
Prior Effective Dates: 1/15/2016
Rule 4729:5-3-19 | Naloxone for emergency use and distribution via automated mechanisms.
 

(A) As used in this rule, "tamper-evident" means a package, storage container or other physical barrier that is sealed or secured in such a way that access to the drugs stored within is not possible without leaving visible proof that such access has been attempted or made.

(B) In accordance with section 4729.515 of the Revised Code, a terminal distributor of dangerous drugs may acquire and maintain a supply of naloxone for use in emergency situations and for distribution through an automated mechanism. The naloxone may be maintained at a location other than the location licensed as a terminal distributor of dangerous drugs.

(C) In the case of naloxone for use in emergency situations, a terminal distributor of dangerous drugs shall do all of the following:

(1) Provide written materials regarding the emergency administration of naloxone to any individual who accesses the naloxone, to include:

(a) Specific instruction to summon emergency services pursuant to division (D)(2) of section 4729.515 of the Revised Code.

(b) Procedures for administering naloxone contained within the kit, including the possible administration of multiple doses.

(c) Performing rescue breathing and the use of a face shield or other rescue breathing barrier device, which shall be provided with the naloxone.

(d) Proper method for placing an individual into the recovery position.

(2) Specify a process to be used to notify the terminal distributor that the naloxone has been accessed within a reasonable time of its being accessed, which may include any of the following:

(a) Documented checks of the emergency naloxone and its required components, to be conducted at least every thirty days, by an employee of the terminal distributor of dangerous drugs. The terminal distributor shall include a telephone number where persons can report that the emergency naloxone has been used and needs replenishment.

(b) An automated alert that notifies the terminal distributor when the emergency naloxone is accessed.

(c) Any other method approved by the board's executive director or the director's designee.

(3) Except in instances where naloxone is not commercially available, including the absence of a manufacturer for the drug or the lack of a readily available supply of the drug from a manufacturer or wholesaler, a terminal distributor of dangerous drugs shall replace any naloxone and, if missing or used, any required components (instructions, rescue breathing barrier device, etc.) no later than forty-eight hours following notification that naloxone has been accessed in accordance with paragraph (C)(2) of this rule.

(4) Maintain the naloxone in accordance with the manufacturer's or distributor's instructions.

(a) All naloxone maintained for emergency use in accordance with this paragraph shall be sealed in a tamper-evident manner to ensure the integrity of the drug.

(b) Any naloxone that shows sign of tampering or adulteration shall be immediately removed by the terminal distributor of dangerous drugs and replaced within forty-eight hours of discovering the naloxone has been tampered with or is adulterated.

(c) A terminal distributor shall develop and implement a policy to ensure that naloxone that exceeds its manufacturer's expiration date is removed and properly disposed.

(5) A terminal distributor maintaining naloxone in accordance with this paragraph shall:

(a) Maintain a complete list that includes the address and description of the location (e.g. first floor hallway, second floor conference room, etc.) of where the terminal distributor maintains the naloxone for emergency use. The list shall be immediately available for inspection upon request of an employee of the board.

(b) Keep a record of the naloxone maintained for emergency use that includes the name, strength, dosage form, national drug code and expiration date. Records shall be readily retrievable and maintained for a period of three years.

(c) Ensure the naloxone is maintained in a container or device that is securely fastened to a permanent structure and is clearly marked to indicate naloxone is available for emergency use.

(6) The requirements of this paragraph shall not apply to a service entity that maintains naloxone for emergency administration in accordance section 4729.514 of the Revised Code.

(D) In the case of naloxone for distribution through an automated mechanism, a terminal distributor of dangerous drugs shall do all the following:

(1) Ensure the mechanism is securely fastened to a permanent structure or is of an appropriate size and weight to reasonably prevent it from being removed from its intended location.

(2) Develop a process to be used to monitor and replenish the inventory of naloxone maintained in the automated mechanism, which may include any of the following:

(a) Documented checks of the mechanism, to be conducted at least every thirty days, by an employee of the terminal distributor of dangerous drugs.

(b) An electronic system to monitor the inventory of naloxone within the mechanism.

(c) Any other method approved by the Board's executive director or the director's designee.

(3) Provide written educational materials to the person accessing the naloxone appropriate to the dosage form of naloxone distributed, including, but not limited to, all of the following:

(a) Risk factors of opioid overdose.

(b) Strategies to prevent opioid overdose.

(c) Signs of opioid overdose.

(d) Steps in responding to an overdose, including:

(i) The proper method for placing an individual into the recovery position.

(ii) Specific instruction to summon emergency services pursuant to division (D)(2) of section 4729.515 of the Revised Code.

(e) Information on naloxone.

(f) Procedures for administering naloxone.

(g) Proper storage and expiration of naloxone product distributed.

(h) Information on where to obtain a referral for substance abuse treatment.

(i) Information, as required in paragraph (D)(4) of this rule, on where individuals may call for additional questions regarding naloxone administration. The telephone number must include the hours where an appropriately trained representative is available to answer questions.

(4) Provide a telephone number where individuals can call representatives with the requisite training necessary to answer questions regarding naloxone administration.

(5) Maintain the naloxone in accordance with the manufacturer's or distributor's instructions.

(a) Any naloxone that shows sign of tampering or adulteration shall be immediately removed by the terminal distributor of dangerous drugs.

(b) A terminal distributor shall develop and implement a policy to ensure that naloxone that exceeds its manufacturer's expiration date is removed and properly disposed.

(6) A terminal distributor maintaining naloxone in accordance with this paragraph shall:

(a) Maintain a complete list that includes the address and description of the location (e.g. first floor hallway, second floor conference room, etc.) of where the terminal distributor maintains an automated mechanism. The list shall be immediately available for inspection upon request of an employee of the board.

(b) Maintain a record of the naloxone stored within the automated mechanism that includes the name, strength, dosage form, national drug code and expiration date. Records shall be readily retrievable and maintained for a period of three years.

(7) Naloxone removed from an automated mechanism shall not be returned to the mechanism or transferred in accordance with rule 4729:5-3-09 of the Administrative Code, except if it was removed by an employee of the terminal distributor of dangerous drugs.

(E) The state board of pharmacy may grant variances from this rule in cases in which:

(1) The applicable provision is not statutorily mandated.

(2) Granting the variance would not:

(a) Be contrary to public interest; or

(b) Compromise the integrity of the drug.

(3) No party will be injured by the granting of the variance.

(F) An approval for a variance pursuant to paragraph (E) of this rule may be revocable, may be granted for a limited period or may be granted subject to the conditions as the state board of pharmacy may prescribe.

Last updated April 8, 2021 at 1:19 PM

Supplemental Information

Authorized By: 4729.26, 4729.54, 4729.55, 4729.515
Amplifies: 4729.26, 4729.54, 4729.55, 4729.515
Five Year Review Date: 4/1/2026
Rule 4729:5-3-20 | Pharmacy pilot or research projects.
 

(A) The purpose of this rule is to specify the process and procedures to be followed when a licensee petitions for approval of a pilot or research project for innovative system applications in the practice of pharmacy that are not currently permitted under agency 4729 of the Administrative Code. In reviewing projects, the board shall consider only projects that expand pharmaceutical care services that contribute to positive patient outcomes.

(B) A project shall not expand the definition of the practice of pharmacy as set forth in Chapter 4729. of the Revised Code and shall not apply to licensees regulated under Chapter 3796. of the Revised Code.

(C) Approval of a project by the board may include the grant of a limited exception to or a waiver of rules adopted under Chapter 4729. of the Revised Code. Project approval, including limited exception to or waiver of board rules, shall initially be for a specified period of time not exceeding twenty-four months from commencement of the project.

(D) Following the completion of the project period, the board may do any of the following based upon a review of the final project report submitted in accordance with paragraph (I) of this rule and any other factors or information the board deems necessary:

(1) Refuse to extend or renew the project;

(2) Approve the extension or renewal of a project following consideration of a petition that clearly identifies the need for extension and must include a report similar to the final project report, which should describe and explain any proposed changes to the originally approved and implemented project, and that justifies the need for extending or renewing the term of the project; or

(3) Approve the project in perpetuity following a consideration of a petition that clearly identifies and justifies the need to continue the project indefinitely.

(E) A licensee who wishes the board to consider approval of a project shall submit to the board a petition for approval that contains at least the following information:

(1) Responsible pharmacist. Name, address, telephone number, and pharmacist license number of each pharmacist responsible for overseeing the project.

(2) Location of project. Name, address, and telephone number of each specific location and, if a location is a pharmacy, the pharmacy's terminal distributor of dangerous drugs license number where the proposed project will be conducted.

(3) Project summary. A detailed summary of the proposed project that includes at least the following information:

(a) The goals, hypothesis, and objectives of the proposed project.

(b) A full explanation of the project and how it will be conducted.

(c) The time frame for the project including the proposed start date and length of the project. The time frame may not exceed eighteen months from the proposed start date of the project.

(d) Background information or literature review to support the proposed project.

(e) The rule or rules to be waived in order to implement the project, an explanation of why such a waiver would not be a detriment to the public, to include procedures to be used during the project to ensure that the public health and safety are not compromised as a result of the waiver, and a request to waive the rule or rules.

(F) Projects submitted shall be reviewed as follows:

(1) Staff review. Upon receipt of a petition for approval of a project, board staff shall initially review the petition. If the petition is incomplete or fails to meet the board's outlined purpose, staff shall return the petition to the requestor with a letter explaining the reason the petition is being returned. A petition that has been returned pursuant to this paragraph may be amended or supplemented as necessary and submitted for reconsideration. A petition that is deemed appropriate and complete shall move on the board member review process.

(2) Board member review. After initial staff review, two members of the board, appointed by the board president, shall be provided the petition and any additional materials. Board members shall conduct a review, in consultation with appropriate staff, and make a recommendation to the full board. Board members conducting a review may request additional documentation and information from the petitioner as part of this review process.

(3) Board review. Following the board member review, the board shall consider the project request at a regularly scheduled meeting of the board. Upon review, the board shall either approve or deny the petition. The board shall not approve any such project if such proposal might jeopardize public health or welfare. If the board approves the petition, the approval:

(a) Shall be specific for the project requested, with any modifications the Board deems necessary for patient safety;

(b) Shall approve the project for a specific time period; and

(c) May include conditions or qualifications applicable to the project, including limited waivers of applicable/related rules.

(G) The project site and project documentation shall be available for inspection and review by the board or its representative(s) at any time during the approval or denial processes and, if a project is approved, throughout the approved term of the project.

(H) Project documentation shall be maintained in a readily retrievable manner and available for inspection, review, and copying by the board or its representative for at least three years following completion or termination of the project.

(I) The pharmacist responsible for overseeing a project shall be responsible for submitting to the board any reports required as a condition of a project, including the final project report.

(1) The final project report shall include a written summary of the results of the project and the conclusions drawn from those results. The final project report shall be submitted to the board within ninety days after completion or termination of the project.

(2) The board shall review any required report regarding the progress of a project and the final project report at a regularly scheduled meeting of the board.

(J) The board may rescind approval and terminate projects, including those it has approved in perpetuity, pursuant to the following:

(1) If the board deems the project does not the comply with the requirements of this rule or the conditions of its approval, the board shall provide notice to the pharmacist responsible for the project indicating the project's approval has been rescinded. The notice shall provide sixty days for the pharmacist to address any deficiencies prior to the termination of the project. If the deficiencies cited in the notice are addressed, the board may reinstate the project prior to its proposed termination date.

(2) If the board has reasonable cause to believe the project poses a threat of immediate or serious harm to the public, the board shall provide notice to the pharmacist responsible for the project indicating the project's approval has been rescinded. The termination of the project shall take effect immediately.

(K) The petitioner and/or project's responsible person may terminate the project earlier than requested but shall provide notice within three business days of termination and a final project report to the board to include an explanation of why the project was terminated early. Upon either recission of approval or early project termination, any waivers granted will be immediately revoked and the licensee will be required to adhere to those rules that had been excepted or waived.

(L) All documents pertaining to the application, project, and reports are considered a public record under section 149.43 of the Revised Code and will be provided upon request, without notice to the project's petitioners and/or responsible person. Petitioners asserting that some or all of an application contains information exempt from disclosure under Ohio law shall comply with the following:

(1) Submit a memorandum identifying the content not subject to disclosure under section 149.43 of the Revised Code, including supporting legal authority for each assertion.

(2) Submit a redacted version of the materials that the applicant agrees may be released without prior notice to the applicant.

(M) By submitting the application, the petitioner understands, acknowledges, and agrees to all of the following:

(1) The board may independently assess the merits of any public records exception claims made by the petitioner.

(2) The board may reject a claim that information in an application is trade secret or a security or infrastructure record if it determines that the petitioner has not established that the content in question meets a delineated exception to public disclosure under Ohio law, including the use of generic language encompassing substantial portions of the application submission or simple assertions of a document containing information exempt from public disclosure, without substantive explanation of the basis.

(3) The state of Ohio does not assume liability for the use or disclosure of any unredacted material.

(4) The board is required to comply with section 149.43 of the Revised Code, which is construed liberally in favor of broad access, and any doubt shall be resolved in favor of disclosure of public records.

(N) The board will make reasonable efforts to determine the initial approval or denial of a project submission within ninety days of the submission of a completed project petition in accordance with paragraph (E) of this rule.

The board shall be required to make the initial approval or denial of a project submission within one hundred and eighty days of the submission of a completed project petition in accordance with paragraph (E) of this rule. This timeframe may be extended by the board for good cause.

(O) Unless otherwise approved by the board, a petition shall be deemed abandoned if the petitioner fails to submit any requested documentation or information within thirty days after being notified by the board. The board shall not be required to act on any abandoned petition and the petition may be destroyed by board staff. If the petition is abandoned, the petitioner shall be required to resubmit a new petition for consideration pursuant to the requirements of this rule.

Last updated September 11, 2023 at 11:43 AM

Supplemental Information

Authorized By: 4729.26, 4729.54, 4729.541, 3719.28
Amplifies: 4729.26, 4729.54, 4729.541, 3719.28
Five Year Review Date: 1/20/2028
Rule 4729:5-3-21 | Point of dispensing locations during a public health emergency.
 

(A) A board of health, as defined in section 3701.048 of the Revised Code, that is licensed as a terminal distributor of dangerous drugs may temporarily remove dangerous drugs upon the governor's declaration of an emergency that affects the public health.

(B) The dangerous drugs removed from a location licensed as a terminal distributor shall be used to establish a point of dispensing location or locations in the event of a declared public health emergency to administer, deliver, dispense, or distribute drugs in accordance with protocols developed pursuant to section 3701.048 of the Revised Code.

(C) The dangerous drugs shall be returned to the board of health within seventy-two hours of the cessation of the public health emergency. An individual listed in divisions (B) and (C) of section 3701.048 of the Revised Code shall maintain personal supervision and control over the dangerous drugs removed from the terminal distributor.

(D) If personal supervision is not provided, the dangerous drugs shall be physically secured in a manner to prevent unauthorized access and diversion. The drugs shall be stored at temperatures which will ensure the integrity of the drugs prior to their use as stipulated by the USP/NF and/or the manufacturer's or distributor's labeling.

(E) All point of dispensing sites established in accordance with this rule shall cease to operate upon the cessation of the public health emergency but may be extended at the request of the director of health.

(F) The board's executive director, upon consultation with the board president, may grant variances or extensions to the requirements set forth in this rule if it is determined that such a variance is in the public interest.

Last updated October 6, 2023 at 8:42 AM

Supplemental Information

Authorized By: 4729.26, 3719.28
Amplifies: 4729.01, 4729.54, 4729.56, 3701.048
Five Year Review Date: 10/6/2028