--- title: "Pharmacy Quality & Compliance Guide | WCGTX" description: "Explore pharmacy and medication-safety guidance for Texas freestanding ERs, with 47 searchable topics and a 65-item fillable PDF readiness checklist." image: "https://wcgtx.com/og-cover-v2.jpg" url: "https://wcgtx.com/facility-resources/pharmacy-quality-compliance/" --- Facility Resources · Pharmacy Source Review: September 2026 # Pharmacy Quality *& Compliance Guide* Review medication management, pharmacy oversight, storage, and patient-safety practices in one searchable resource. Browse topics Use readiness checklist Download Fillable PDF Checklist **Educational Resource, Not a Compliance Certification.** Adapted from the supplied departmental guide and blank checklist. The guide states a source review date of September 2026; this is not an independent verification of current requirements. Confirm applicability with current official sources and qualified facility leadership. Checklist selections are self-reported, not an assessment by WCGTX. Start Here ## Your Department’s Working Reference Browse 47 guide topics, review 65 readiness items, or download the fillable PDF checklist for your team. The full guide is available on this page. Read. Review. Follow Through. Search the guide · Review readiness · Save a fillable PDF checklist Review the five readiness questions About This Guide and Its Scope A Practical Resource Based on Texas State Board of Pharmacy, Texas HHSC, and Joint Commission Quality Expectations Medication management is one of the highest-risk clinical systems within an emergency-care environment. For a Texas Freestanding Emergency Room, pharmacy compliance extends well beyond maintaining medication inventory. A strong pharmacy program must address: - Pharmacy licensure - Pharmacist oversight - Medication procurement - Formulary management - Storage and security - Controlled substances - Emergency medications - Medication orders - Drug distribution - Outpatient medications - Medication reconciliation - High-alert medications - Adverse drug reactions - Medication errors and near misses - Drug recalls - Expiration management - Temperature control - Pharmacy records - Staff access - Quality assessment and QAPI This guide provides a practical framework for aligning Freestanding Emergency Room pharmacy operations with: Texas State Board of Pharmacy (TSBP) Texas Health and Human Services Commission (HHSC) 26 TAC Chapter 509 Texas Pharmacy Act and Board Rules Joint Commission Ambulatory Health Care medication-management expectations Browse the Guide ## Find a Pharmacy Topic Search pharmacy topics Search the full guidance inside all 47 topics. All Regulatory & Oversight Medication Storage & Supply Security & Controlled Substances Emergency Medication Safety Orders & Patient Care Quality Improvement & Readiness 47 topics Clear filters Expand all Jump to a Topic Readiness checklist Fillable PDF checklist Reference library 01 Regulatory & Oversight ### Texas Class F Pharmacy Requirement Texas State Board of Pharmacy rules establish a specific pharmacy class for Freestanding Emergency Medical Care Facilities. Read Guidance Texas State Board of Pharmacy rules establish a specific pharmacy class for Freestanding Emergency Medical Care Facilities. #### Class F Pharmacy A Class F pharmacy license authorizes a pharmacy located within a Freestanding Emergency Medical Care Facility that provides emergency care. TSBP identifies Class F as: #### Freestanding Emergency Medical Care Center Pharmacy The detailed operational standards are contained primarily in: #### 22 TAC §291.151 — Pharmacies Located in a Freestanding Emergency Medical Care Facility (Class F) This section establishes requirements addressing: - Pharmacy personnel - Pharmacist-in-charge responsibilities - Pharmacy environment - Medication storage - Security - Controlled substances - Drug distribution - Outpatient medications - Pharmacy records - Drug regimen review - Policies and procedures Texas pharmacies must also maintain accessible copies of applicable pharmacy laws and rules. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 1. 02 Regulatory & Oversight ### Texas HHSC Pharmaceutical Services Requirements Texas HHSC regulates Freestanding Emergency Medical Care Facilities under: Read Guidance Texas HHSC regulates Freestanding Emergency Medical Care Facilities under: #### 26 TAC Chapter 509 The pharmacy-specific section is: #### 26 TAC §509.50 — Pharmaceutical Services This provision requires a Texas Freestanding Emergency Medical Care Facility to: - Be licensed as required by the Texas State Board of Pharmacy. - Adopt, implement, and enforce policies and procedures for pharmaceutical services. - Provide drugs, controlled substances, and biologicals safely and effectively according to professional practice. - Comply with applicable state and federal pharmaceutical laws. - Ensure contracted pharmacy services meet the same professional, ethical, and legal standards as directly provided services. Pharmacy compliance should therefore be treated as both a TSBP pharmacy requirement and an HHSC facility requirement. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 2. 03 Regulatory & Oversight ### Pharmacist-in-Charge Each Class F pharmacy must have a Pharmacist-in-Charge (PIC). Read Guidance Each Class F pharmacy must have a Pharmacist-in-Charge (PIC). Under 22 TAC §291.151, the PIC may be employed or contracted on at least a consulting or part-time basis. The PIC has significant responsibility for the overall medication-management system. Responsibilities include oversight of: - Medication procurement - Medication storage - Formulary development - Drug distribution - Pharmacy labeling - Emergency medications - Antidotes - Controlled substances - Pharmacy records - Drug utilization - Pharmacy policies - Automated medication systems - Pharmaceutical quality activities The rule also requires a pharmacist to visit the facility at least once during each calendar week that the facility is open. A survey-ready facility should maintain documentation of each pharmacist visit. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 3. 04 Regulatory & Oversight ### Weekly Pharmacy Inspection The weekly pharmacist visit should be substantive. Read Guidance The weekly pharmacist visit should be substantive. A practical inspection should include review of: #### Medication Storage - Proper storage conditions - Medication organization - Security - Refrigerator integrity - Controlled substance storage #### Expiration - Expired medications - Short-dated medications - Open-vial dating - Multi-dose vial dating - Emergency medications #### Controlled Substances - Inventory reconciliation - Waste documentation - Diversion concerns - Discrepancy investigation #### Emergency Medication Supplies - Crash carts - Emergency drug trays - Antidotes - Resuscitation medications #### Pharmacy Records - Drug distribution - Outpatient medication records - Controlled substance records - Medication returns #### Quality Issues - Medication errors - Adverse reactions - Recalls - Storage excursions - Pharmacy-related incidents Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 4. 05 Regulatory & Oversight ### Pharmacy Policies and Procedures Texas Class F pharmacy rules require written drug-distribution policies. Read Guidance Texas Class F pharmacy rules require written drug-distribution policies. 22 TAC §291.151 identifies numerous required or expected policy topics, including: - Controlled substances - Investigational drugs - Medication errors - Physician/practitioner orders - Floor stock - Adverse drug reactions - Patient's own medications - Self-administration - Emergency drug trays - Formulary - Drug storage - Drug samples - Drug product defects - Drug recalls - Outdated drugs - IV admixtures - Automated medication systems - Data processing systems - Drug regimen review The pharmacy policy manual should therefore reflect the facility's actual workflow rather than simply using a generic pharmacy template. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 5. 06 Medication Storage & Supply ### Formulary Management A Freestanding ER should maintain an approved medication formulary or medication list appropriate to its emergency-care scope. Read Guidance A Freestanding ER should maintain an approved medication formulary or medication list appropriate to its emergency-care scope. The formulary should consider: - Emergency medications - Resuscitation drugs - Analgesics - Sedatives - Antiemetics - Antibiotics - Antihypertensives - Cardiac medications - Antidotes - Pediatric medications - Procedural medications - Contrast-related medications - Reversal agents Under Texas Class F pharmacy rules, the pharmacist-in-charge participates in formulary development and is a voting member of committees involving pharmaceutical services. The formulary should be periodically reviewed for: Safety • Utilization • Availability • Cost • Clinical necessity • Shortages Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 6. 07 Medication Storage & Supply ### Medication Procurement Medication procurement should occur through authorized and approved sources. Read Guidance Medication procurement should occur through authorized and approved sources. The pharmacy should have controls addressing: - Approved wholesalers - Receiving - Invoice verification - Drug integrity - Controlled-substance receipt - Recall tracking - Lot tracking where appropriate - Product shortages - Substitute medications The PIC is responsible for determining specifications for medications procured by the facility. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 7. 08 Medication Storage & Supply ### Medication Storage All medications should be stored under conditions that protect: Read Guidance All medications should be stored under conditions that protect: Identity • Strength • Quality • Purity • Stability Storage should follow manufacturer requirements. Texas rules specifically require medications to be stored at appropriate temperatures and prohibit dispensing or distribution after the medication expiration date. Outdated medications must be removed from active stock and quarantined pending appropriate disposition. Joint Commission similarly requires organizations to protect medications against unauthorized access, tampering, theft, and diversion. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 8. 09 Medication Storage & Supply ### Temperature Management Medication refrigerators and other temperature-sensitive storage areas should have a reliable monitoring process. Read Guidance Medication refrigerators and other temperature-sensitive storage areas should have a reliable monitoring process. A good system should identify: - Acceptable temperature range - Current temperature - Minimum/maximum temperature when applicable - Monitoring frequency - Responsible staff - Escalation procedures - Medication disposition after excursions Joint Commission does not prescribe a specific paper temperature log, but requires medications to be stored according to manufacturer instructions and expects the organization to maintain a process that demonstrates appropriate temperatures are being maintained. When an excursion occurs: Do not automatically discard or continue using the medication. Instead: Quarantine → Evaluate manufacturer stability information → Document determination → Release or dispose Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 9. 10 Security & Controlled Substances ### Medication Security Medication security should prevent unauthorized: Read Guidance Medication security should prevent unauthorized: - Access - Removal - Tampering - Theft - Diversion Texas Class F pharmacies must maintain secure medication storage areas. Only individuals authorized by the pharmacist-in-charge should have access to pharmacy or drug-storage areas. Joint Commission also defines medication security based on protection from unauthorized access, tampering, theft, or diversion. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 10. 11 Security & Controlled Substances ### Controlled Substances Controlled substances represent one of the highest-risk pharmacy areas. Read Guidance Controlled substances represent one of the highest-risk pharmacy areas. Class F pharmacies must maintain systems establishing receipt and distribution of controlled medications. Importantly, Texas requires a perpetual inventory of Schedule II–V controlled substances. A pharmacist must: - Verify completeness - Reconcile the inventory - Perform this reconciliation at least once during each calendar week that the pharmacy is open This became an explicit focus of the 2023 amendment to §291.151. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 11. 12 Security & Controlled Substances ### Controlled-Substance Discrepancies Every discrepancy should be resolved promptly. Read Guidance Every discrepancy should be resolved promptly. A controlled-substance discrepancy investigation should document: Medication → Expected Quantity → Actual Quantity → Difference → Staff Involved → Investigation → Resolution Potential causes may include: - Documentation error - Medication waste - Incorrect count - Patient administration not charted - Return not documented - Inventory entry error - Diversion Unresolved discrepancies should be escalated immediately according to pharmacy and facility policy. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 12. 13 Security & Controlled Substances ### Controlled-Substance Waste Controlled substances that are partially administered or otherwise wasted should have clearly documented disposal. Read Guidance Controlled substances that are partially administered or otherwise wasted should have clearly documented disposal. The process should address: - Medication - Dose removed - Dose administered - Amount wasted - Date/time - Patient - Person administering - Witness where required - Disposal method The facility should periodically trend: Waste discrepancies • Late waste documentation • Unusual usage patterns • Override activity Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 13. 14 Security & Controlled Substances ### Diversion Prevention Medication diversion prevention should be part of the pharmacy quality program. Read Guidance Medication diversion prevention should be part of the pharmacy quality program. A useful monitoring strategy includes: - Controlled-substance inventory variance - Automated dispensing cabinet overrides - Frequent cancellations - Excessive waste - Unusual medication removal times - Individual staff usage patterns - Missing medications - Documentation discrepancies Texas places responsibility on pharmacy ownership to establish effective controls against theft or diversion. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 14. 15 Emergency Medication Safety ### Emergency Medications and Crash Carts Emergency medications must be immediately available when needed. Read Guidance Emergency medications must be immediately available when needed. Examples may include: - Epinephrine - Atropine - Adenosine - Amiodarone - Calcium - Sodium bicarbonate - Dextrose - Naloxone - Magnesium - Vasopressors - Antihistamines - Reversal agents Texas Class F rules specifically require the PIC to maintain sufficient antidotes and emergency medications and appropriate antidote information. Emergency cart integrity should be checked according to facility policy. Joint Commission permits appropriately secured breakaway-tag systems in continuously staffed emergency areas when there is a defined process for monitoring cart integrity. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 15. 16 Emergency Medication Safety ### Antidotes and Reversal Agents Antidotes should be selected based upon medications used within the facility. Read Guidance Antidotes should be selected based upon medications used within the facility. Potential examples may include: - Naloxone - Flumazenil - Calcium - Glucagon - Dextrose - Protamine - Phytonadione - Lipid emulsion where clinically appropriate Facilities should determine emergency medication locations based on clinical risk. Joint Commission emphasizes that emergency medication selection and location are organizational and medical-staff responsibilities. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 16. 17 Emergency Medication Safety ### High-Alert Medications Organizations should identify which medications within their own formulary represent elevated risk of serious patient harm. Read Guidance Organizations should identify which medications within their own formulary represent elevated risk of serious patient harm. Examples commonly considered high-risk may include: - Insulin - Anticoagulants - Concentrated electrolytes - Neuromuscular blockers - Sedatives - Opioids - Vasopressors The organization should develop a risk-reduction strategy appropriate to each high-alert medication. Joint Commission specifically states that simply posting a generic internet list of high-alert medications does not satisfy its medication-management expectation. The organization must identify its own medications and implement processes for managing the associated risks. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 17. 18 Emergency Medication Safety ### Look-Alike / Sound-Alike Medications Medication storage should reduce the risk of selecting the wrong drug. Read Guidance Medication storage should reduce the risk of selecting the wrong drug. Potential strategies include: - Physical separation - Tall Man lettering - Auxiliary labels - Barcode systems - ADC alerts - Staff education Medication error data should help determine where additional safeguards are needed. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 18. 19 Orders & Patient Care ### Medication Orders Medication administration should be based on a valid medication order unless otherwise allowed through an approved emergency protocol. Read Guidance Medication administration should be based on a valid medication order unless otherwise allowed through an approved emergency protocol. Orders should clearly identify: - Medication - Dose - Route - Frequency - Clinical indication where appropriate Ambiguous or incomplete medication orders should be clarified before administration whenever clinically feasible. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 19. 20 Orders & Patient Care ### Verbal and Emergency Orders Emergency medicine frequently requires verbal orders. Read Guidance Emergency medicine frequently requires verbal orders. The facility should define: - Who may give verbal orders - Who may receive them - Required read-back - Documentation requirements - Authentication process Verbal orders should be used according to facility policy and applicable law. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 20. 21 Security & Controlled Substances ### Automated Dispensing Cabinets If an FSER uses an automated medication dispensing system, pharmacy policies should address: Read Guidance If an FSER uses an automated medication dispensing system, pharmacy policies should address: - Authorized users - Access - Inventory - Controlled substances - Overrides - Restocking - Discrepancies - Downtime - Security - Maintenance Texas Class F rules specifically address automated medication supply systems and require appropriate policies governing operation, accuracy, security, confidentiality, and unauthorized access. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 21. 22 Security & Controlled Substances ### Override Monitoring Emergency departments frequently require medication overrides. Read Guidance Emergency departments frequently require medication overrides. However, override access should not become routine when pharmacist or electronic review would otherwise be available. Organizations should define: - Which medications can be overridden - Which staff may override - Appropriate indications - Retrospective review - Escalation for inappropriate use Override patterns should periodically be reviewed as a patient-safety measure. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 22. 23 Orders & Patient Care ### Pharmacist Medication Review Texas Class F rules require pharmacist involvement in drug-regimen review. Read Guidance Texas Class F rules require pharmacist involvement in drug-regimen review. A pharmacist evaluates medication orders and medication records for factors such as: - Allergies - Contraindications - Appropriate dose - Route - Therapeutic duplication - Drug-drug interactions - Drug-food interactions - Drug-disease interactions - Adverse reactions - Overutilization - Underutilization - Clinical monitoring Texas additionally requires periodic retrospective random drug-regimen review, with no more than 31 days between reviews. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 23. 24 Orders & Patient Care ### Medication Reconciliation Medication reconciliation helps reduce medication discrepancies during emergency treatment and discharge. Read Guidance Medication reconciliation helps reduce medication discrepancies during emergency treatment and discharge. The facility should obtain the most accurate medication history reasonably available, including: - Prescription medications - OTC medications - Supplements when clinically relevant - Allergies - Recent medication changes Joint Commission's 2026 ambulatory guidance confirms that medication-reconciliation requirements apply when medications are administered and/or the patient's medication regimen changes. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 24. 25 Orders & Patient Care ### Medication Allergies Allergies should be documented before medication administration whenever possible. Read Guidance Allergies should be documented before medication administration whenever possible. The record should distinguish: - Drug allergy - Reaction - Intolerance - Unknown reaction Medication allergy overrides should be clinically justified and documented. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 25. 26 Orders & Patient Care ### Medication Labeling Medications prepared but not immediately administered should be appropriately labeled. Read Guidance Medications prepared but not immediately administered should be appropriately labeled. Labels should include enough information to safely identify the medication. Particular attention should be given to: - Syringes - Medication cups - IV bags - Procedural medications - Sedation medications Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 26. 27 Emergency Medication Safety ### IV Medication Safety Intravenous medications should follow standardized policies addressing: Read Guidance Intravenous medications should follow standardized policies addressing: - Preparation - Dilution - Concentration - Compatibility - Infusion rates - Labeling - Administration - Monitoring Facilities should consider standardized concentrations whenever clinically feasible. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 27. 28 Emergency Medication Safety ### Pediatric Medication Safety Pediatric emergency medications carry increased risk because dosing frequently depends on patient weight. Read Guidance Pediatric emergency medications carry increased risk because dosing frequently depends on patient weight. A safe process should address: - Weight in kilograms - Weight-based dosing - Maximum doses - Concentration - Independent verification where appropriate - Pediatric emergency references Medication errors involving pounds-versus-kilograms conversion should be specifically monitored. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 28. 29 Emergency Medication Safety ### Procedural Sedation Medications Medication safety for procedural sedation should address: Read Guidance Medication safety for procedural sedation should address: - Medication selection - Dosing - Monitoring - Reversal medications - Emergency equipment - Documentation - Recovery Reversal agents should be readily available when clinically indicated. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 29. 30 Orders & Patient Care ### Medications Brought by the Patient A facility should have a policy covering medications brought from home. Read Guidance A facility should have a policy covering medications brought from home. The policy should address: - Identification - Storage - Security - Administration - Documentation - Return to the patient Texas Class F pharmacy rules expressly include patient-supplied medications among required policy areas. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 30. 31 Orders & Patient Care ### Outpatient / Take-Home Medications Texas Class F pharmacies may provide medications for outpatient use under specified controls. Read Guidance Texas Class F pharmacies may provide medications for outpatient use under specified controls. Key requirements include: - Medication supplied only to facility patients - Approved outpatient medication list - Appropriate prepackaging and labeling - Practitioner completion of the label - Controlled distribution - Perpetual documentation With specified exceptions, Texas rules limit such medications to a 72-hour supply. The PIC or designated pharmacist must review those records at least once each calendar week the pharmacy is open. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 31. 32 Medication Storage & Supply ### Drug Recalls Every pharmacy should maintain a recall process. Read Guidance Every pharmacy should maintain a recall process. When a recall is received: Identify → Locate → Quarantine → Remove → Document → Notify if necessary Documentation should include: - Medication - Lot - Manufacturer - Recall date - Inventory affected - Disposition - Patient notification if clinically required Texas Class F rules specifically require drug-recall policies. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 32. 33 Medication Storage & Supply ### Expired Medication Management Expired medications should never remain available for patient use. Read Guidance Expired medications should never remain available for patient use. Routine inspections should include: - Pharmacy stock - Medication rooms - Crash carts - Procedure rooms - Refrigerator - Automated cabinets - Respiratory medications - Contrast-related medications Outdated products should be segregated from usable medications pending disposal. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 33. 34 Quality Improvement & Readiness ### Medication Errors Medication errors should be reported through the facility quality system. Read Guidance Medication errors should be reported through the facility quality system. Examples include: - Wrong patient - Wrong medication - Wrong dose - Wrong route - Wrong time - Omitted dose - Duplicate dose - Incorrect infusion - Documentation errors The objective should be to identify both individual and system contributing factors. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 34. 35 Quality Improvement & Readiness ### Near Misses Near misses should also be reported. Read Guidance Near misses should also be reported. A near miss provides an opportunity to correct a weakness before patient harm occurs. Examples may include: - Wrong medication retrieved but caught - Incorrect dose intercepted - Allergy warning identified before administration - Incorrect concentration discovered before infusion Organizations should encourage reporting without creating a punitive reporting culture. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 35. 36 Quality Improvement & Readiness ### Adverse Drug Reactions The facility should maintain a process for identification, clinical management, documentation, and review of adverse drug reactions. Read Guidance The facility should maintain a process for identification, clinical management, documentation, and review of adverse drug reactions. Potential quality measures include: - Serious ADRs - Contrast reactions - Anaphylaxis - Unexpected medication responses - Reversal-agent use Texas Class F rules expressly require adverse-drug-reaction policies. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 36. 37 Medication Storage & Supply ### Medication Shortages Drug shortages can create significant emergency-care risks. Read Guidance Drug shortages can create significant emergency-care risks. The facility should maintain a process for: - Identifying shortages - Notifying clinical staff - Selecting alternatives - Updating protocols - Limiting inventory when appropriate - Avoiding unsafe substitutions Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 37. 38 Quality Improvement & Readiness ### Pharmacy Downtime Plan The facility should have contingency procedures for: Read Guidance The facility should have contingency procedures for: - ADC outage - EMR outage - Power failure - Refrigerator failure - Pharmacy computer failure - Medication shortage - Controlled-substance system outage Staff should know how emergency medications will remain accessible while maintaining appropriate accountability. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 38. 39 Regulatory & Oversight ### Pharmacy Records Texas Class F pharmacy records generally must be maintained for at least two years unless another law requires a longer period. Read Guidance Texas Class F pharmacy records generally must be maintained for at least two years unless another law requires a longer period. Records should be retrievable for inspection. Electronic systems may be used if they contain all required information and can produce appropriate records when requested. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 39. 40 Regulatory & Oversight ### Controlled-Substance Records Controlled-substance records should demonstrate the complete movement of medication through the facility: Read Guidance Controlled-substance records should demonstrate the complete movement of medication through the facility: Receipt → Inventory → Distribution → Administration → Waste/Return → Disposal Records should support accountability for Schedule II–V medications. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 40. 41 Regulatory & Oversight ### Pharmacy Reference Library Texas requires Class F pharmacies to maintain accessible pharmacy references. Read Guidance Texas requires Class F pharmacies to maintain accessible pharmacy references. These include current: - Texas Pharmacy Act and rules - Texas Dangerous Drug Act/rules - Texas Controlled Substances Act/rules - Federal controlled-substance requirements - Drug information reference - Drug interaction information - Antidote information - Regional Poison Control contact information Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 41. 42 Quality Improvement & Readiness ### Medication Quality Dashboard A monthly FSER Pharmacy Dashboard can include: Read Guidance A monthly FSER Pharmacy Dashboard can include: #### Safety - Medication errors - Near misses - Adverse drug reactions - Allergy-related events #### Controlled Substances - Inventory discrepancies - Waste discrepancies - Unresolved discrepancies - Diversion investigations #### Storage - Temperature excursions - Expired medication findings - Storage deficiencies #### Emergency Medications - Crash-cart deficiencies - Emergency medication shortages #### Pharmacist Oversight - Weekly inspections completed - Controlled substance reconciliation completed - Drug-regimen reviews completed #### Medication Reconciliation - Completion rate - Identified discrepancies #### Quality - Drug recalls - Corrective actions - Repeat deficiencies Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 42. 43 Quality Improvement & Readiness ### Monthly Pharmacy Quality Review The pharmacy component of the FSER QAPI meeting should answer: Read Guidance The pharmacy component of the FSER QAPI meeting should answer: #### Licensure Is the Class F pharmacy license current? #### Pharmacist Oversight Were required pharmacist visits completed? #### Controlled Substances Was weekly perpetual inventory reconciliation completed? #### Security Were medications protected against unauthorized access and diversion? #### Storage Were medication temperature and storage requirements maintained? #### Expiration Were any expired medications identified? #### Emergency Medications Were crash carts and emergency medication supplies complete? #### Medication Errors Were errors and near misses investigated? #### Adverse Drug Events Were clinically significant reactions appropriately reviewed? #### Recalls Were drug recalls appropriately handled? #### Corrective Action Were previous findings resolved and effectiveness verified? Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 43. 44 Quality Improvement & Readiness ### Pharmacy QAPI Model A practical performance-improvement process is: Read Guidance A practical performance-improvement process is: IDENTIFY → ANALYZE → CORRECT → MEASURE → SUSTAIN #### Example: Finding: Three expired medications found during inspection. Root Cause: Inconsistent expiration review process. Corrective Action: Monthly expiration sweep + 90-day short-dated medication tracking. Owner: Pharmacy/PIC. Goal: Zero expired medications available for patient use. Follow-Up: Zero findings for three consecutive months. Status: Effectiveness Verified / Closed. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 44. 45 Regulatory & Oversight ### Joint Commission Medication-Management Expectations Joint Commission Ambulatory Health Care medication-management requirements focus broadly on safe medication systems. Read Guidance Joint Commission Ambulatory Health Care medication-management requirements focus broadly on safe medication systems. Important concepts include: - Medication security - Accurate medication information - High-alert medication risk reduction - Safe storage - Manufacturer storage requirements - Medication labeling - Medication error reduction - Safe administration - Emergency medication availability Joint Commission continues to maintain Ambulatory medication-management and National Patient Safety Goal requirements in 2026. Its National Performance Goals introduced in 2026 apply specifically to Hospital and Critical Access Hospital programs, while Ambulatory Health Care retains its own program-specific safety framework. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 45. 46 Quality Improvement & Readiness ### Survey-Ready Pharmacy Binder A practical Pharmacy Survey Binder could include: Read Guidance A practical Pharmacy Survey Binder could include: #### Section 1 — Licensure - Current Class F pharmacy license - PIC designation - Pharmacist licenses - DEA documentation as applicable #### Section 2 — Pharmacy Oversight - Pharmacist contract - Weekly inspection records - Pharmacist visit documentation - Committee participation #### Section 3 — Policies - Medication management policy - Controlled substance policy - Drug distribution policy - Emergency medication policy - Medication error policy - ADR policy - Recall policy - Storage policy - Outpatient medication policy #### Section 4 — Controlled Substances - Perpetual inventory - Weekly reconciliations - Waste documentation - Discrepancy investigations - Destruction records #### Section 5 — Storage - Refrigerator monitoring - Room temperature monitoring when applicable - Expiration inspections - Medication security audits #### Section 6 — Emergency Medications - Crash-cart checks - Antidote list - Emergency formulary #### Section 7 — Quality - Medication-error reports - Near-miss reports - ADR reports - Pharmacy quality dashboard - QAPI projects - Corrective-action tracking #### Section 8 — References - Current Texas pharmacy laws - TSBP rules - Controlled-substance laws - Drug reference - Poison-control resources Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 46. 47 Quality Improvement & Readiness ### Five Questions Every FSER Pharmacy Should Be Able to Answer During a survey, leadership should be able to demonstrate: Read Guidance During a survey, leadership should be able to demonstrate: 1\. Who is responsible for pharmacy oversight? 2\. How do you know medications are secure and stored properly? 3\. How do you account for every controlled substance? 4\. What happens when a medication error or adverse event occurs? 5\. How do you know your corrective actions worked? A mature pharmacy program should be able to answer each question with both policy and supporting documentation. Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms, Section 47. Quick Reference ## Five Questions Every FSER Pharmacy Should Be Able to Answer Use these questions to guide a discussion with department leadership. They do not replace the detailed review or applicable requirements. 1. Who is responsible for pharmacy oversight? 2. How do you know medications are secure and stored properly? 3. How do you account for every controlled substance? 4. What happens when a medication error or adverse event occurs? 5. How do you know your corrective actions worked? During a survey, leadership should be able to demonstrate: A mature pharmacy program should be able to answer each question with both policy and supporting documentation. Review Your Readiness ## Pharmacy Survey Readiness Checklist Review all 65 items from the supplied checklist. The framework labels reproduce the source’s reference columns; they are not independently verified regulatory determinations. **Session-Only Tool.** Selections stay in this page and are not saved or submitted. They reset when you reload or leave. Do not enter patient information. Use the downloadable fillable PDF checklist for facility details, findings, due dates, and sign-off. Search Checklist Items Filter by Status Reset selections 0 of 65 reviewed · 0 marked deficient 65 checklist items shown ### Licensure, Operations, Security & Controlled Substances Item 01 Current Texas Class F Pharmacy License is available and reflects the correct facility name and location. Source References: TSBP · HHSC Review Status Item 02 Pharmacy license and required regulatory documentation are current and readily available for inspection. Source References: TSBP · HHSC Review Status Item 03 A qualified Pharmacist-in-Charge (PIC) is formally designated. Source References: TSBP · HHSC · TJC Review Status Item 04 PIC responsibilities are documented and actively performed. Source References: TSBP · TJC Review Status Item 05 Required pharmacist facility visits are completed and documented for each calendar week the facility is open. Source References: TSBP Review Status Item 06 Weekly pharmacy inspection records are complete and available. Source References: TSBP · TJC Review Status Item 07 Pharmacy policies and procedures are current, approved, available to staff, and match actual practice. Source References: TSBP · HHSC · TJC Review Status Item 08 Current pharmacy formulary / approved medication list is maintained. Source References: TSBP · HHSC · TJC Review Status Item 09 Emergency medications and antidotes appropriate to the FSER scope of services are available. Source References: TSBP · HHSC · TJC Review Status Item 10 Pharmacy and medication-storage areas are secured against unauthorized access. Source References: TSBP · HHSC · TJC Review Status Item 11 Access to pharmacy and medication areas is restricted to authorized personnel. Source References: TSBP · HHSC · TJC Review Status Item 12 Medication storage areas are clean, organized, and appropriate for medications stored. Source References: TSBP · HHSC · TJC Review Status Item 13 Medications are stored according to manufacturer temperature, light, humidity, and security requirements. Source References: TSBP · HHSC · TJC Review Status Item 14 Medication refrigerators/freezers are monitored according to policy and manufacturer requirements. Source References: TSBP · HHSC · TJC Review Status Item 15 Temperature excursions have documented investigation, medication disposition, and corrective action. Source References: TSBP · HHSC · TJC Review Status Item 16 No expired medications are available for patient use. Source References: TSBP · HHSC · TJC Review Status Item 17 Short-dated medications are identified and tracked before expiration. Source References: TSBP · TJC Review Status Item 18 Expired medications are removed from active inventory and appropriately quarantined/disposed. Source References: TSBP · HHSC · TJC Review Status Item 19 Medication recalls are reviewed, affected inventory is identified, and disposition is documented. Source References: TSBP · HHSC · TJC Review Status Item 20 Medication procurement is through appropriately authorized suppliers. Source References: TSBP · HHSC · TJC Review Status Item 21 Controlled substances are stored securely with access limited to authorized personnel. Source References: TSBP · HHSC · TJC Review Status Item 22 Schedule II-V controlled substances are maintained through an appropriate perpetual inventory system. Source References: TSBP · TJC Review Status Item 23 Controlled substance inventory is reconciled at the required frequency by the pharmacist. Source References: TSBP · TJC Review Status Item 24 Controlled-substance discrepancies are promptly investigated and resolved. Source References: TSBP · HHSC · TJC Review Status Item 25 Controlled-substance waste is appropriately documented and witnessed when required. Source References: TSBP · HHSC · TJC Review Status Item 26 Controlled-substance receipt, administration, waste, return and disposal records are traceable. Source References: TSBP · HHSC · TJC Review Status Item 27 Processes exist for identifying and escalating possible medication diversion. Source References: TSBP · HHSC · TJC Review Status Item 28 Automated dispensing cabinets, if used, restrict access to authorized personnel. Source References: TSBP · HHSC · TJC Review Status Item 29 ADC user access is periodically reviewed and terminated promptly when employment/authorization ends. Source References: TSBP · TJC Review Status Item 30 ADC overrides are defined by policy and retrospectively monitored. Source References: TSBP · TJC Review Status Item 31 ADC discrepancies are investigated and documented. Source References: TSBP · TJC Review Status Item 32 Crash carts and emergency medication trays are secured and checked according to facility policy. Source References: TSBP · HHSC · TJC Review Status Item 33 Crash-cart medication expiration dates and quantities are routinely verified. Source References: TSBP · HHSC · TJC Review Status Item 34 Pharmacy downtime procedures address ADC failure, EMR outage, refrigeration failure, power loss, and medication shortages. Source References: TSBP · HHSC · TJC Review Status Item 35 Required pharmacy records are retained and readily retrievable during a survey. Source References: TSBP · HHSC · TJC Review Status ### Medication Safety, Quality, QAPI & Leadership Review Item 36 Medication orders contain sufficient information for safe administration. Source References: TSBP · HHSC · TJC Review Status Item 37 Verbal/telephone medication orders follow approved policy, including read-back/authentication requirements. Source References: TSBP · HHSC · TJC Review Status Item 38 Patient medication allergies and reactions are documented and available to clinicians before administration when feasible. Source References: HHSC · TJC Review Status Item 39 Medication reconciliation is completed according to the facility scope and applicable accreditation requirements. Source References: HHSC · TJC Review Status Item 40 Medication discrepancies identified during reconciliation are addressed appropriately. Source References: HHSC · TJC Review Status Item 41 Medications prepared but not immediately administered are appropriately labeled. Source References: TSBP · HHSC · TJC Review Status Item 42 IV medication preparation, dilution, concentration, labeling and administration follow approved policy. Source References: TSBP · HHSC · TJC Review Status Item 43 Pediatric weights are documented in kilograms and weight-based medication dosing is used when appropriate. Source References: HHSC · TJC Review Status Item 44 High-alert medications used by the facility are specifically identified. Source References: HHSC · TJC Review Status Item 45 High-alert medication risk-reduction strategies are implemented and monitored. Source References: HHSC · TJC Review Status Item 46 Look-alike / sound-alike medication risks are addressed through storage, labeling, technology, or other controls. Source References: TSBP · HHSC · TJC Review Status Item 47 Procedural sedation medications and reversal agents are appropriately available, secured and monitored. Source References: HHSC · TJC Review Status Item 48 Patient-supplied medications are managed according to written policy. Source References: TSBP · HHSC · TJC Review Status Item 49 Outpatient/take-home medication processes comply with applicable Class F pharmacy requirements. Source References: TSBP · HHSC · TJC Review Status Item 50 Take-home medication labeling contains required patient, medication and practitioner information. Source References: TSBP · HHSC · TJC Review Status Item 51 Outpatient medication distribution is appropriately documented and reviewed by pharmacy. Source References: TSBP · HHSC · TJC Review Status Item 52 Required pharmacist drug-regimen reviews are completed and documented. Source References: TSBP · TJC Review Status Item 53 Significant pharmacist interventions are communicated to the practitioner and documented. Source References: TSBP · TJC Review Status Item 54 Medication errors are reported, investigated and incorporated into the quality program. Source References: TSBP · HHSC · TJC Review Status Item 55 Medication near misses are reported and trended for system improvement. Source References: HHSC · TJC Review Status Item 56 Adverse drug reactions are identified, treated, documented and reviewed. Source References: TSBP · HHSC · TJC Review Status Item 57 Serious or recurring medication events receive root-cause or focused review when appropriate. Source References: HHSC · TJC Review Status Item 58 Medication error and ADR trends are reported through QAPI / Quality Committee processes. Source References: HHSC · TJC Review Status Item 59 Pharmacy-related complaints or patient-safety concerns are reviewed for trends. Source References: HHSC · TJC Review Status Item 60 Drug shortages and therapeutic substitutions are communicated to clinical staff and managed safely. Source References: TSBP · HHSC · TJC Review Status Item 61 Pharmacy reference materials, current laws/rules, drug information and poison-control resources are accessible. Source References: TSBP Review Status Item 62 Previous TSBP, HHSC, Joint Commission or internal pharmacy deficiencies have documented corrective action. Source References: TSBP · HHSC · TJC Review Status Item 63 Corrective actions are followed to determine whether improvement was effective. Source References: HHSC · TJC Review Status Item 64 Pharmacy performance data are reported regularly to appropriate facility leadership. Source References: HHSC · TJC Review Status Item 65 Pharmacy QAPI projects have measurable goals, owners, due dates and outcome measures. Source References: HHSC · TJC Review Status Checklist Scope and Instructions Texas State Board of Pharmacy • Texas HHSC • Joint Commission Facility: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Class F Pharmacy License #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Pharmacist-in-Charge: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Review Month/Year: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Reviewed By: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Medical Director: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Status Key: ☐ C = Compliant ☐ D = Deficient ☐ N/A Crosswalk: TSBP = Texas State Board of Pharmacy / 22 TAC §291.151 | HHSC = 26 TAC Chapter 509 / §509.50 | TJC = applicable Joint Commission Ambulatory medication-management and patient-safety expectations IMMEDIATE-ATTENTION FINDINGS: Critical Finding(s): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Immediate Action: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Owner: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Due: \_\_\_\_\_\_\_\_\_ Monthly Pharmacy Quality Dashboard The indicators and goals below are copied from the supplied worksheet. They are template goals, not independently verified or universal regulatory thresholds. Use the fillable PDF checklist to record current and prior measurements and follow-up actions. | Indicator | Source Worksheet Goal | | --- | --- | | Weekly pharmacist visits completed | 100% | | Weekly controlled-substance reconciliations | 100% | | Controlled-substance discrepancies | 0 unresolved | | Controlled-substance waste discrepancies | 0 unresolved | | Medication errors | Trend review | | Medication near misses | Trend review | | Adverse drug reactions | Trend review | | High-alert medication events | 0 preventable | | Medication-reconciliation compliance | Facility Goal | | Crash-cart deficiencies | 0 | | Expired medication findings | 0 | | Temperature excursions | 0 unresolved | | Drug recalls outstanding | 0 | | ADC discrepancies | 0 unresolved | | Pharmacy inspection deficiencies | 0 unresolved | | Pharmacist regimen review compliance | 100% | Corrective Action and Leadership Review Indicator | Current | Goal | Prior | Trend / Action ### Corrective Action & Effectiveness Tracker - Finding - Immediate - Root Cause - Corrective Action - Owner - Due - Effectiveness - Status ### Pharmacy Leadership Review HIGH - What went well? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ LOW - What did not meet expectations? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ BLOCKER - What is preventing compliance or improvement? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ DECISION NEEDED - What requires PIC, Medical Director, Administrator, or Governing Body action? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ### Survey-Readiness Status ☐ Survey Ready ☐ Minor Corrective Actions ☐ Corrective Action Required ☐ Immediate Leadership Review ### Sign-Off Pharmacist-in-Charge: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_ Facility Administrator: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_ Medical Director: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_ Quality / Compliance Representative: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_ CLOSING STANDARD: FINDING -> IMMEDIATE CORRECTION -> ROOT CAUSE -> CORRECTIVE ACTION -> MEASUREMENT -> EFFECTIVENESS VERIFIED -> CLOSED References: Texas State Board of Pharmacy, 22 TAC §291.151 (Class F); Texas HHSC, 26 TAC Chapter 509 including §509.50; current Joint Commission Ambulatory Health Care medication-management/patient-safety standards; applicable federal controlled-substance requirements. Internal readiness tool only; verify current rules and standards. Last reviewed: September 2026. Wellness & Care Group of Texas | Internal Quality & Survey Readiness Resource Use the fillable PDF checklist to record your review and follow-up. Sign-off is an internal review step, not a certification by WCGTX. “Reviewed” means a status has been selected, including Not Applicable. No overall “Survey Ready” or compliance score is generated. Keep a Working Copy ## Download the Fillable PDF Checklist Read the guide on this page. Download the checklist to record and save your facility’s review. Fillable PDF ### Pharmacy Survey Readiness Checklist The complete 65-item checklist, with editable review statuses, a monthly quality dashboard, corrective actions, and leadership review fields. [Download Fillable PDF Checklist](https://wcgtx.com/resources/pharmacy-survey-readiness-checklist-fillable.pdf) Open in a PDF reader that supports fillable forms and save your completed copy securely. Website selections are not transferred to the PDF. Do not enter patient information. Keep the Source in View ## References & Regulatory Resources These links and reference notes come from the supplied guide. Requirements may depend on the facility’s services, licenses, accreditation, equipment, and current regulations. Confirm current applicability before use. 1. [Texas State Board of Pharmacy — Pharmacy Laws & Rules (opens in a new tab)](https://www.pharmacy.texas.gov/Rules/) Texas Pharmacy Act and Texas Pharmacy Rules. 2. [Texas Pharmacy Rules (opens in a new tab)](https://www.pharmacy.texas.gov/Rules_Pharmacy_Rules.asp) Texas Administrative Code pharmacy rules. 3. [TSBP Class F Pharmacy Licensing (opens in a new tab)](https://www.pharmacy.texas.gov/applicants/new-pharmacy.asp) Class F — Freestanding Emergency Medical Care Center Pharmacy. 4. [Joint Commission — Ambulatory Health Care National Patient Safety Goals (opens in a new tab)](https://www.jointcommission.org/en-us/standards/national-patient-safety-goals) Source Reference Notes ### Regulatory References ### Texas State Board of Pharmacy 22 TAC §291.151 — Pharmacies Located in a Freestanding Emergency Medical Care Facility (Class F) Primary Texas pharmacy operational rule for Freestanding Emergency Medical Care Facilities. ### Texas Health and Human Services Commission ### 26 TAC Chapter 509 — Freestanding Emergency Medical Care Facilities Key pharmaceutical section: ### 26 TAC §509.50 — Pharmaceutical Services Requires the facility to: - Maintain appropriate TSBP licensure - Implement pharmaceutical-service policies - Provide drugs and controlled substances safely - Comply with state and federal requirements - Hold contracted pharmacy services to equivalent standards Texas Freestanding Emergency Medical Care Facilities are regulated by HHSC under Health and Safety Code Chapter 254 and 26 TAC Chapter 509. ### The Joint Commission Joint Commission — Medication Reconciliation Guidance Maintaining and Communicating Patient Medication Information. ### Joint Commission — Medication Security / Emergency Cart Guidance ### Joint Commission — High-Alert and Hazardous Medication Guidance ### Joint Commission — Medication Storage and Temperature Guidance Important Disclaimer Important Disclaimer This resource is intended for education, internal quality improvement, and survey preparedness. It is not: Legal advice An official Texas State Board of Pharmacy interpretation An official HHSC interpretation An official Joint Commission interpretation A replacement for current pharmacy regulations or accreditation standards Each facility should verify requirements against: Current Texas State Board of Pharmacy rules Current 22 TAC §291.151 Current Texas Pharmacy Act Current 26 TAC Chapter 509 Current federal controlled-substance requirements Current Joint Commission Ambulatory Health Care standards Current manufacturer medication-storage requirements The facility's pharmacy license The facility's actual medication formulary and scope of services Source: Pharmacy Quality & Compliance Guide for Texas Freestanding Emergency Rooms and Texas Freestanding Emergency Room Pharmacy Survey-Readiness Checklist. Supplied by Wellness & Care Group of Texas. Presented as a searchable reference with the original blank fillable PDF checklist; no independent regulatory certification is implied. 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