(1) In an institutional facility that does not have an in-house pharmacy, drugs may be provided for use by authorized personnel through emergency kits prepared by the registered pharmacist providing pharmaceutical services to the facility. Such emergency drug kits must meet all of the following requirements:
(a) a registered pharmacist shall prepare and seal the kit;
(b) the supplying pharmacist and the designated practitioner or appropriate committee of the institutional facility shall jointly determine the identity and quantity of drugs to be included in the kit. Such drugs shall then be approved in advance of placement in the emergency kit by the board; unless such drugs are included on a general list of drugs previously approved by the board for use in emergency kits;
(c) the kit must be locked and stored in a secure area to prevent unauthorized access and to ensure a proper storage environment for the drugs contained therein. The kit shall be secured with a seal to be of such a nature that it can be easily identified if it has been broken;
(d) all drugs in the kit must be properly labeled, including lot number and expiration date, and shall possess any additional information that may be required to prevent risk of harm to the patient;
(e) the exterior of the kit must be clearly labeled to indicate:
(i) its use and expiration date of its contents;
(ii) the name, address and telephone number of the supplying pharmacist; and
(iii) a statement indicating that the kit is to be used in emergency situations only pursuant to a valid drug order.
(2) Drugs shall be removed from emergency kits only by the supplying pharmacist or by authorized personnel pursuant to a valid drug order.
(3) Upon notice of any entry into the kit, the supplying pharmacist or another pharmacist designated by the supplying pharmacist shall restock and refill the kit, reseal the kit, and update the drug listing on the exterior of the kit within 72 hours.
(4) The expiration date of a kit must be the earliest date of expiration of any drug supplied in the kit. On or before the expiration date, the supplying pharmacist shall replace the expired drug.
(5) The supplying pharmacist shall, in conjunction with the appropriate institutional committee, be responsible for development of policies and procedures for safe and appropriate use and maintenance of emergency drug kits.