1.4 The Pharmacist-in-Charge (PIC): Duties, Self-Audits & Notifications
Key Takeaways
Each Class A or B pharmacy that needs a PIC must have one full-time PIC, who may also be PIC of another Class A or B pharmacy that is not open at the same time (R156-17b-302(6)).
The PIC must ensure DOPL is notified of a change in PIC within 30 days of the change (R156-17b-603(3)(s)).
A pharmacy self-audit is due within 30 days of a PIC change, within 30 days of a new facility opening, and at least 90 days before the end of each renewal cycle.
Each completed self-audit form must be kept for two years from the date of the self-audit (R156-17b-603(3)(u)(iv)).
The pharmacy's single self-audit email address must be reported, and any change reported to DOPL within seven calendar days.
1.4 The Pharmacist-in-Charge (PIC): Duties, Self-Audits & Notifications
Utah law puts personal responsibility for each pharmacy on a named pharmacist. Under § 58-17b-612(1)(a), every pharmacy except a wholesaler, distributor, out-of-state mail service pharmacy, or Class E pharmacy must be under the general supervision of at least one Utah-licensed pharmacist, and one Utah pharmacist must be designated pharmacist-in-charge (PIC) to oversee the pharmacy's operation. Under § 58-17b-302(6), whenever a law requires or prohibits action by a pharmacy, the PIC and the owner are responsible.
Who may be PIC, and of how many pharmacies
R156-17b-302(6) sets the rule the MPJE tests:
- Each Class A and Class B pharmacy that needs a PIC or DMPIC must have one PIC or DMPIC who is employed full time (as the employer defines it) and acts as PIC for one pharmacy.
- The PIC may be PIC of more than one Class A or Class B pharmacy if the other pharmacies are not open to provide pharmacy services at the same time.
- The PIC may also serve as a remote dispensing PIC (RDPIC). In a remote dispensing arrangement, the supervising pharmacy's PIC serves as the RDPIC, and an RDPIC may not be RDPIC for more than one remote dispensing pharmacy unless DOPL approves it in collaboration with the board (R156-17b-614g(4)).
Important
There is no "waiver" process for this. The question is whether the pharmacies are open at the same time. A pharmacist may be PIC of a weekday clinic pharmacy and a weekend-only pharmacy, but not of two stores that are open during the same hours.
A pharmacy license applicant's PIC must consent to and complete a criminal background check (§ 58-17b-306(1)(f); R156-17b-307).
The PIC's duties (R156-17b-603)
The PIC (or consulting pharmacist, RDPIC, or DMPIC) must be personally in full and actual charge of the pharmacy. The PIC is responsible for:
| Area | Duty |
|---|---|
| Dispensing | Ensure only a pharmacist, intern, DMP, or DMP designee dispenses, including packaging, preparation, compounding, and labeling, and that drugs are dispensed safely and accurately |
| Delivery and information | Ensure drugs are delivered safely and accurately; ensure patients receive drug information on request; make a reasonable effort to obtain and keep patient medication records |
| Personnel | Educate and train staff; ensure every staff member holds the right license; ensure staffing ratios do not create an unreasonable risk of harm |
| Drug control | Set procurement policies; control storage, disposal, distribution, and bulk compounding; keep records that account for all drugs; maintain effective controls against theft and diversion |
| Systems | Keep electronic records compliant; run a quality assurance program for any automated pharmacy system; ensure accurate and timely Controlled Substance Database submissions |
| Legal operation | Meet inspection requirements and all state and federal laws |
| Notices and audits | Record the PIC with DOPL and report a PIC change within 30 days; use one email address for self-audits and alerts and report a change within 7 calendar days; complete self-audits on schedule |
The PIC is also responsible for required inventories. The PIC may delegate the counting, but the PIC must sign and date the inventory within 72 hours or three working days of an initial, annual, change-of-ownership, or closing inventory (R156-17b-605(2)).
Self-audits (§ 58-17b-103; R156-17b-603(3)(u))
DOPL may require a self-audit instead of, or in addition to, an on-site inspection. The PIC completes it on a DOPL form:
- within 30 days of a change of PIC, consulting pharmacist, DMPIC, or RDPIC;
- within 30 days of opening a new facility; and
- at least 90 days before the end of each renewal cycle. Pharmacy licenses expire September 30 of odd-numbered years, so this falls in early July of those years.
Each completed self-audit form must be kept for two years from the date of the self-audit. Missing the deadline and giving false information on a self-audit are both unprofessional conduct (R156-17b-502(8), (9)).
Notification timelines
| Event | Deadline | Source |
|---|---|---|
| Change of PIC (or consulting pharmacist, RDPIC, DMPIC, designated representative, responsible party) | Within 30 days | R156-17b-603(3)(s); R156-17b-502(21) |
| Change of the self-audit email address | Within 7 calendar days | R156-17b-603(3)(t); R156-17b-502(23) |
| Self-audit after PIC change or new facility | Within 30 days | R156-17b-603(3)(u) |
| Closure, ownership change, name change, or relocation | At least 10 business days before (see Section 1.5) | § 58-17b-614 |
Discipline tied to PIC failures
Failing to meet PIC standards is unprofessional conduct under R156-17b-502(16). Operating a pharmacy with no licensed pharmacist designated as PIC is unprofessional conduct under § 58-17b-502(1)(k). DOPL's fine schedule (R156-17b-402) lists, for example, a first-offense range of $100–$500 for failing to report a PIC change within 30 days.
Scenarios
- Two stores, same hours. A chain asks a Sandy PIC to also be PIC of its Draper store, which is open during the same hours. Not permitted: the pharmacies are open at the same time.
- Weekday/weekend split. A PIC runs a Monday–Friday clinic pharmacy and is asked to be PIC of a Saturday-only pharmacy owned by the same company. Permitted, because the two are not open at the same time.
- New PIC starts September 1. The self-audit is due by October 1 and must be kept on file until September 2028 (two years from the date the audit was performed).
A pharmacist is full-time PIC of a Monday-through-Friday clinic pharmacy. The owner asks her to also be PIC of a Saturday-only retail pharmacy. Under R156-17b-302(6), may she accept?
Only if DOPL grants a written waiver after a board hearing
Yes, because a PIC may be PIC of more than one Class A or B pharmacy if the pharmacies are not open at the same time
Only if the pharmacies are within 15 miles of each other
No, because a pharmacist may never be PIC of more than one pharmacy
Which schedule of pharmacy self-audits matches Utah Admin. Code R156-17b-603(3)(u)?
Within 30 days of a PIC change, within 30 days of opening a new facility, and at least 90 days before the end of each renewal cycle
Only when DOPL sends a written request after an inspection
Within 10 days of a PIC change and every January 1
Within 60 days of a PIC change and within 60 days after each license renewal
How long must a Utah pharmacy keep a completed self-audit form?
One year, or until the next self-audit
Five years, like prescription files
Until the pharmacy license is next renewed
Two years from the date of the self-audit
A pharmacy changes the email address it uses for DOPL self-audits and pharmacy alerts. When must DOPL be notified?
Within 30 days, the same deadline as a PIC change
Within seven calendar days of the change
At the next license renewal
Within 10 business days before the change takes effect
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