Free 35890.FH11 - Indiana

INDIANA BOARD OF PHARMACY INSPECTION REPORT
State Form 35890 (R6 / 2-06)

Name of pharmacy Address (number and street, city, state, and ZIP code)

Today's date and time CSR number Name of pharmacist in charge

County Pharmacy permit number Type

Telephone number

(

)

DEA number General appearance Open for business Weekly hours License current?

Total weekly hours Present Absent

Pharmacist in charge matches permit? License number

Yes For items below, C = compliant; N = non-compliant.
C N NA

No For names of other pharmacists employed, see attached sheet. INSPECTION CHECKLIST

TECHNICIANS Are pharmacy technicians properly employed according to law? How many? ____________ Are pharmacy technicians operating within the scope of the law / regulations / name tags? PHARMACY AREAS

License displayed?

Yes

No

Is the pharmacy equipped as required by law? Are current reference sources and law readily available? Are all pharmaceuticals in date and stored with expiration and lot number as required? Other ____________ Video Alarm system Approved security system in place? Pharmacy complies with temperature requirements (59° - 89° F). Is any type of mechanical device utilized for dispensing medications? Proper packing systems are utilized; medications are properly stored and labeled. Satellite pharmacies are being utilized. 797 regulations being followed? Date of last hood certification (month, day, year): ________________________ PATIENT RECORDS Prescription files are properly kept? Compliance with dispensing of special medications (e.g. Clozaril, Thalomid, Accutane, etc.)? GENERAL SUBSTITUTION Proper prescription format used (i.e. generic law)? Are generic substitutions properly documented? CONTROLLED SUBSTANCE Date of last biennial inventory (month, day, year)? DEA ________ Stored type ________ Locked up ________ Dispersed _______ Are federal DEA forms properly kept? Schedule V and syringe register kept and controlled by pharmacist? Compliant with INSPECT program. Procedure for destruction of controlled substances? GENERAL Patient counseling being offered? Are all certificates properly displayed, current or correct? How do you handle return or expired medications? Pharmacy documents (e.g. orders, invoices) reviewed? Any deficiencies found? If yes, what? ______________________________________________________________________________ Are computer records, including on line retrieval of prescription status, properly kept? Printout of prescription order and refill data first each days dispensing on request? Are prescription transfers properly performed? HIPAA compliance. Have all thefts and shortages been reported to the Board of Pharmacy? Has an effort been made to comply with previous inspection requests?
Note irregularities in number or type of prescriptions on file and other comments:

Pursuant to 856 IAC 1-6.1, I,

Name of pharmacist

, hereby acknowledge and understand all notations made on this report and

confirm that I will notify the Indiana Board of Pharmacy within 30 days, in writing, of the correction of all deficiencies (if any noted).
Signature of owner, pharmacist or employee Signature of inspector

DISTRIBUTION: White - Inspector; Canary - Pharmacy; Pink - Board file