12.1 Pharmacy Operations: Pharmacist Presence, Policies, Equipment, Signage, Hours & Closures
Key Takeaways
An Oregon pharmacy may operate only while an Oregon-licensed pharmacist is physically present, and must be kept clean with appropriate infection control.
Oregon outlets must keep written policies on security, dispensing, technician use, procurement, disposal (including hazardous waste), confidentiality, closure plans, training and language services.
Oregon pharmacies must keep current references, Oregon and federal law, USP standards and three years of Board newsletters, and must have access to PDMP, NPLEx and ALERT IIS.
Required Oregon pharmacy signs include the generic-substitution notice, interpretation services, opioid antagonist availability and accurate hours.
For a temporary closure, an Oregon pharmacy posts notice within 2 hours and notifies the Board within 72 hours if the closure exceeds 2 business days; a permanent closure requires 15 days' patient notice.
Why this matters
Area 4.2 opens with "non-dispensing requirements for operations of pharmacies." These are the rules a compliance officer checks on a walk-through: a pharmacist on site, equipment and references, signage, written policies, posted hours, closure procedures and a safe working environment. Oregon codifies them in OAR 855-041-1010 to -1095 and the Board's annual self-inspection form.
A pharmacist must be present (OAR 855-041-1015)
A pharmacy may operate only when an Oregon-licensed pharmacist is physically present in the pharmacy or institutional facility. The pharmacy must be kept clean, and staff must practice appropriate infection control. When no pharmacist is present, the pharmacy is secured (section 12.3). Technicians may be in the pharmacy area only when a pharmacist is physically present. Remote dispensing sites operating under telepharmacy rules are the exception.
General outlet duties (OAR 855-041-1018)
Each drug outlet pharmacy must:
- Comply with all applicable state and federal law, including the specific rules for prescriptions, controlled substances, compounding and radiopharmaceuticals.
- Train every licensee before they practice or assist in the practice of pharmacy, and ensure each person performs only duties they are licensed and trained for.
- Be responsible for the actions of every licensed and non-licensed person.
- Establish, maintain and enforce written procedures.
- Run a quality improvement program that monitors care, improves outcomes, and finds the root causes of dispensing and DUR errors to prevent recurrence.
Required written policies (OAR 855-041-1040)
| Policy area | Examples of content |
|---|---|
| Security | Diversion prevention, key and code control, closing procedures |
| Systems and equipment | Operation, testing and maintenance |
| Sanitation; drug storage | Cleaning schedules; cold-chain plan |
| Dispensing | The workflow from intake to release, documenting who performed each step and when |
| Supervision | Pharmacist supervision, direction and control of non-pharmacists; how technicians are used, including final verification and vaccination |
| Procurement, receiving, disposal and delivery | Including hazardous and pharmaceutical waste |
| Use of pharmacists | Who performs DUR and counseling |
| Recordkeeping; confidentiality; continuous quality improvement | |
| Closure | A plan for discontinuing and recovering services if the pharmacy closes |
| Training | Initial and ongoing |
| Language services | Interpretation, translation and prescription reader services |
Pharmacists must review the policies before practicing and with each update, and document the review (OAR 855-115-0105(13)).
Minimum equipment, references and signage (OAR 855-041-1035)
References and access:
- Current pharmaceutical references appropriate to the services provided, for example pharmacology, injectables and veterinary drugs.
- Oregon statutes and rules, federal law, adopted standards such as USP, and three years of Board newsletters. The newsletters are published only online, through NABP's state newsletter page.
- Access to PDMP, NPLEx and ALERT IIS.
Equipment:
- Drug-storage equipment that meets state and federal requirements.
- A sink with hot and cold running water.
- Anything else the pharmacy or PIC considers necessary.
Required signs:
- The generic substitution notice, in letters at least one inch high (ORS 689.515(4)).
- Notice of free interpretation and translation services in the required languages.
- Hours, when operating as a double set-up without a pharmacist present.
- Notice that opioid antagonists are available (ORS 689.806).
- Accurate hours at each entrance.
Hours also appear on every telephone greeting and pharmacy-operated internet platform: website, social media and apps.
Failing to maintain required equipment is unprofessional conduct under ORS 689.405(1)(a). Licenses and registrations, including pharmacy, DEA, pharmacist, intern, preceptor and technician licenses, must be displayed (ORS 689.615; OAR 855-115-0105(11)).
Closures (OAR 855-041-1092)
| Type | Key requirements |
|---|---|
| Temporary (deviating from posted hours) | Post notice at each entrance as soon as the need is known, and no later than 2 hours after the closure begins, with the expected duration and pickup options. Update phone and web. If the closure exceeds 2 consecutive business days, notify the Board within 72 hours with the dates and reason. Holidays are exempt |
| Permanent | At least 15 calendar days before closing, notify patients who filled prescriptions in the past 12 months by direct mail and a newspaper notice, plus posting. Notify DEA of controlled-substance transfers. On the closing date or within 24 hours, inventory controlled substances and transfer records. Within 30 days, finish the non-controlled inventory and disposition and file the Board's closure notice |
| Emergency (fire, disaster, death, eviction and similar) | Meet the temporary-closure steps as soon as circumstances allow |
Working environment (OAR 855-041-1010; OAR 855-041-1170)
The outlet must provide a working environment that protects patients:
- Staffing adequate to prevent fatigue, distraction and similar conditions.
- Appropriate rest periods and meal breaks.
- Enough time for pharmacists to complete their duties.
The pharmacist on duty may temporarily suspend services when safe operation isn't possible. An outlet that overrides or obstructs the pharmacist on duty's control of pharmacy practice, or fails to provide a safe environment, is subject to discipline.
Advertising (OAR 855-041-1095; OAR 855-041-1170)
No person may advertise or claim to operate as a pharmacy, or to provide pharmacy services, unless registered with the Board. Advertising that is false, fraudulent, deceptive or misleading, or that offers inducements to transfer prescriptions, is a ground for outlet discipline.
Tip
"Can the pharmacy stay open for 20 minutes while the only pharmacist runs to the bank?" No. Under OAR 855-041-1015, the pharmacy operates only while a pharmacist is physically present. Under OAR 855-041-1020, it must be secured when no pharmacist is there.
Exam scenario
A staffing shortage forces an unplanned closure of an Oregon retail pharmacy on Tuesday and Wednesday. By no later than 2 hours after closing, the PIC posts notice at the entrances with the expected reopening and pickup options, and updates the phone greeting and website. The closure lasts two business days, which is not more than two, so no Board notice is required. If it ran through Thursday, the PIC would notify the Board within 72 hours.
An Oregon pharmacy will close permanently. At minimum, how far in advance must it notify patients who filled prescriptions there in the past 12 months?
At least 72 hours before closing
At least 30 days before closing
At least 15 calendar days before closing, by direct mail and a newspaper notice, plus posted notice
No notice; the Board notifies patients
Which reference requirement appears in OAR 855-041-1035?
Access to the PDMP, NPLEx and ALERT IIS, and three years of Board of Pharmacy newsletters
A printed copy of the Orange Book updated monthly
Ten years of Board newsletters in paper form
A DEA Pharmacist's Manual signed by the PIC
The only pharmacist on duty must leave the building for 30 minutes. What does Oregon law require?
A technician may continue dispensing refills that have already been verified
The pharmacy may remain open if a COPT is present
Customers may pick up prescriptions from a clerk if they were already bagged
The pharmacy may not operate and must be secured while no pharmacist is physically present
Sections you finish are checked off in the contents.