Hospital Director Change for Dispensary License

Implementation Date: 10/2021

Date of Last Revision: 3/7/2023

Next Review Due: 3/6/2025

 

Reviewed by VTH Administrative Team: 10/2021

Reviewed by VTH Board: N/A

 

Approved by VTH Director: 10/2021

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Director without approval.

Policy

To provide the process for switching the dispensary licenses over when there is a new hospital director. This applies each time a transfer of licensing occurs including switching from a pharmacy to a dispensary and when a new hospital director is appointed. 

All drug ordering accounts must be switched to reflect the current hospital director’s IL state license, IL controlled substance license and DEA license. The director will need to maintain a state controlled substance license and a DEA license for both the VTH and VMSC addresses. When a license switch occurs, the old license holder, new license holder and pharmacy coordinator must complete a complete controlled substance inventory at the point of changeover. This will serve as the closing inventory for the old license holder and the opening inventory for the new license holder. The pharmacy coordinator will maintain this documentation for 7 years.

Guidelines

• When a license switch occurs, the pharmacy coordinator will switch all drug ordering accounts to the new license holder’s information. This will require a new account setup and adding the new information to Vizient to set up the McKesson account for ordering human medications.
• The pharmacy coordinator will coordinate the process of creating a CSOS account with the new director’s DEA number. The pharmacy coordinator will be the CSOS coordinator and the DEA holder will sign up as the registrant.
• Once all drug ordering accounts have been switched and CSOS set up, a complete controlled substance inventory will be completed either before the start of business hours or after the close of business hours for the dispensary. This inventory must be a joint effort between the old license holder, new license holder and pharmacy coordinator.
• The inventory will include the counts of all controlled substances as well as the signatures of the license holders (old and new) and the pharmacy coordinator. The inventory record will be maintained by the pharmacy coordinator for 7 years.

Procedure (if applicable)

Definitions (if applicable)

Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.