SNP03-61 Restocking of Automated Drug Delivery System Rev 9.5

Policy: Restocking of Automated Drug Delivery System (ADDS) Policy Number:
Type: Automated Drug Delivery System SNP03-61
Page 1 of 2

Purpose: The purpose of this policy is to establish guidelines for the restocking of Automated
Drug Delivery System (ADDS) in accordance with California State Board of
Pharmacy guidelines.

1.0 Policy

1.1 All automated drug delivery system(s) will be restocked based on reports
generated by Skilled Nursing Pharmacy.

1.2 The task of placing drugs into the removable pockets, cards, drawers, Cubies or
similar technology is performed at Skilled Nursing Pharmacy by a licensed
pharmacist, pharmacy technician or intern pharmacist under the direct supervision
of a licensed pharmacist and then delivered to the facility in a secure tamper-
evident container.

1.3 Canisters, drawers, or Cubies should be restocked in the ADDS within 48 hours
of receipt from the pharmacy.

2.0 Procedure

2.1 Skilled Nursing Pharmacy will review daily the Cubex C15b Transaction Report
and C2 Control Unresolved Discrepancies Report for each ADDS.

2.2 Medications to be restocked in the automated drug delivery system(s) will be
prepared by a Skilled Nursing Pharmacy licensed pharmacist, pharmacy
technician or intern pharmacist under the direct supervision of a licensed
pharmacist and delivered to the facility in a secure tamper-evident container.

2.2.1 Cubie(s) for restock will be contained in a secure tamper-evident
2.2.2 container sealed with a red zip-tie.
Exchanged cubies from the ADDS will be secured in the tamper-
evident container and sealed with a yellow zip-tie, for return to the
pharmacy.

2.3 Authorized facility personnel will restock medication in the automated drug
delivery system(s) within 48 hours upon receipt of medication from pharmacy.

2.3.1 Authorized ADDS facility nursing personnel shall access the
ADDS using their fingerprint bio ID, or user id and password.

The information contained in this document is the Confidential and Proprietary property of Skilled Nursing Pharmacy. Do not copy
or distribute without permission from Skilled Nursing Pharmacy.

Policy: Restocking of Automated Drug Delivery System (ADDS) Policy Number:
Type: Automated Drug Delivery System SNP03-61
Page 2 of 2

2.3.2 Authorized ADDS facility nursing personnel shall access the
ADDS using their Bio ID fingerprint or user ID and password to restock
medication received utilizing the restock function.

2.3.3 Authorized ADDS facility nursing personnel will verify the quantity
being restocked.

2.3.4 If drugs or devices are not immediately restocked into an ADDS upon arrival at
the ADDS location, the drugs and devices shall be stored for no longer than 48
hours in a secured room/location within the licensed ADDS location.

2.3.4.1 If the removable pockets, cards, drawers, or Cubies are received but not
restocked in the ADDS after 48 hours, they must be returned to the
pharmacy. Pharmacy security parameters prohibit the Cubie(s) from
being restocked after 48 hours of receipt.

2.3.5 When restocking is complete, authorized ADDS facility nursing personnel
will close the automated drug delivery system and sign off from the system.

Prepared by: Flynn Lew Pharm.D. Version 9.5 Effective Date: 07/01/19
Chief Compliance Officer Approved Date: 05/10/19

Approved by: Ben Mandelbaum

Manager Approved and Implemented by: Implementation Date:

Revised: (dates) Approved: (dates) Implemented: (dates)

_______________0510/19_________ _____05/10/19___________________ ________05/10/19_________________

The information contained in this document is the Confidential and Proprietary property of Skilled Nursing Pharmacy. Do not copy
or distribute without permission from Skilled Nursing Pharmacy.