Any hospital, long-term care facility, or pharmacy that uses an automated medication system shall develop, maintain, and comply with policies and procedures developed in consultation with the pharmacist responsible for pharmacist care for that hospital, long-term care facility, or pharmacy. At a minimum, the policies and procedures shall address the following:

(1) The description and location within the hospital, long-term care facility, or pharmacy of the automated medication system or equipment being used;

(2) The name of the pharmacist responsible for implementation of and compliance with the policies and procedures;

(3) Medication access and information access procedures;

(4) Security of inventory and confidentiality of records in compliance with state and federal laws, rules, and regulations;

(5) A description of the process used by a pharmacist or pharmacy technician for filling an automated medication system;

(6) A description of how and by whom the automated medication system is being utilized, including processes for verifying, dispensing, and distributing medications;

(7) Staff education and training;

(8) Quality assurance and quality improvement programs and processes;

(9) Inoperability or emergency downtime procedures;

(10) Periodic system maintenance; and

(11) Medication security and controls.