(1) The pharmacy shall develop a policy and procedure manual relating to sterile products and home infusion therapy. The manual must be available for inspection at the pharmacy.

(2) The pharmacist-in-charge shall review and revise the manual on an annual basis.

(3) The manual must specifically detail the storage, stability, handling, compounding, labeling, dispensing and delivery of all sterile pharmaceuticals and address requirements relating to:

(a) security measures, which ensure that the premises where sterile pharmaceuticals are present are secured, and which prevent access to patient records by unauthorized personnel;

(b) sanitation, including the methodology of cleaning biological safety cabinets and laminar flow hoods, and of inspecting filters for deterioration and microbial contamination;

(c) the annual certification of safety cabinets and laminar floor hoods;

(d) the orientation of personnel;

(e) the duties and qualifications of staff;

(f) record keeping requirements;

(g) medication profiles;

(h) the administration of parenteral therapy to include infusion devices, drug delivery systems and first dose monitoring;

(i) the pharmacy patient evaluation and documentation;

(j) prescription processing;

(k) clinical services;

(l) drug and product selection;

(m) 24 hour emergency access to a pharmacist;

(n) the handling of antineoplastic agents;

(o) drug destruction, returns, and proper waste management;

(p) equipment management, including tracking, cleaning, and testing of infusion pumps;

(q) end product testing;

(r) a quality assessment program;

(s) a risk management program including incident reports,

adverse drug reactions, product contamination, and drug recalls;

(t) education and training of the patient or the patient's caregiver;

(u) emergency drug and supply procurement;

(v) guidelines for handling investigational drug administration;

(w) reference materials; and

(x) an emergency preparedness plan.