(1) In order for drugs to be stored in a designated area outside the pharmacy including, but not limited to, floor stock, in an emergency cabinet, in an emergency kit, or as emergency outpatient drug delivery from an emergency department at a registered institutional facility, the following conditions must be met:

(a) Drugs stored in such a manner shall remain under the control of, and be routinely monitored by, the supplying pharmacy;

(b) The supplying pharmacy shall develop and implement policies and procedures to prevent and detect unauthorized access, document drugs used, returned and wasted, and regular inventory procedures;

(c) Access to drugs stored in a designated area outside of the pharmacy must be limited to health care professionals licensed under the chapters specified in RCW 18.130.040 acting within their scope, and nursing students as provided in WAC 246-945-450, except as provided in subsection (2) of this section;

(d) The designated area is appropriately equipped to ensure security and protection from diversion or tampering; and

(e) The designated area must be located in a facility licensed or otherwise authorized by law to possess and store drugs.

(2) An unlicensed employee or contractor of the receiving facility may access drugs stored in the designated area if all of the following are met:

(a) The unlicensed employee or contractor is acting within their scope of employment or contract;

(b) The unlicensed employee or contractor is accessing drugs for the purpose of supply chain management at the receiving facility;

(c) The unlicensed employee or contractor is only accessing drugs listed in a policy and procedure that is readily retrievable by the supplying pharmacy; and

(d) The unlicensed employee or contractor is not accessing controlled substances.

(3) For nursing homes and hospice programs an emergency kit or supplemental dose kit must comply with RCW 18.64.560.