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Based on records reviewed and interviews, the Hospital failed for two of three Department of Pharmacy Employees (Pharmacist #1 and Pharmacist #2), to ensure that each pharmacist requiring a license and or certification for the practice of pharmacy, had verification of a registered, valid and current pharmacy license to ensure and promote the highest standards of professional practice, as required by State laws, and Hospital Policies and Procedures.

The Hospital's Department of Pharmacy Policy and Procedure regarding Verification of Employee Licensure, Registration and Certification, dated, 8/1/14, indicated that the Department of Pharmacy was responsible to obtain proof of licensure and certification when applicable from all personnel pertaining to his/her job title such as pharmacist, pharmacy technician or pharmacy intern.

The State Law for the Commonwealth of Massachusetts, Board of Registration in Pharmacy 4.02: Personal Registration Expiration and Renewal indicated the following:

(1) All personal registrations shall expire on December 31st of each even-numbered year and
shall be renewed prior to January 1 of the following year if the registrant intends to continue his or her practice of pharmacy.

(2) A registrant who has not renewed his or her personal registration before the date of its expiration may renew such registration upon payment of an annual license fee, applicable back license fees, and a late fee as established by the Commissioner of Administration and Finance under Massachusetts General Law c. 7, § 3B.

(3) Any practice of pharmacy by a registrant after the expiration of his or her personal registration shall constitute the unlicensed practice of pharmacy and shall be subject to any and all penalties established for such unlicensed practice of pharmacy.

The Hospital's Human Resources Policy and Procedure titled Performance Review, dated February 2002, for all employees, indicated performance reviews were conducted at least annually for employees to provide a formal record of an employee's job performance.

Pharmacist #1's personnel file, reviewed on 2/22/17, indicated an annual performance appraisal was conducted on 3/14/16 that indicated Pharmacists #1's primary source licensure verification was up-to-date; however, continued review of the file indicated Pharmacist #1 did not have a valid and current license to practice pharmacy.

The Surveyor interviewed the Director of Employee Relations at 1:00 P.M. on 2/21/17. The Director of Employee Relations said she received a telephone call from the Director of the Pharmacy who reported that Pharmacist #1 did not renew her license before December 2014 and did not have a current and valid license to practice pharmacy. The Director of Employee Relations said, when the lapse in license renewal was identified, the employee was sent home from work and the incident was reported to the Massachusetts Board of Registration in Pharmacy.

Pharmacist #2's personnel file was reviewed on 2/22/17 and indicated that his last performance appraisal was dated 2008. There was no current performance appraisal and no current verification of a valid current license to practice pharmacy.

The Surveyor interviewed the Chief Medical Officer at 2:00 P.M. on 2/22/17. The Chief Medical Officer said that a current performance appraisal and verification of a current license to practice pharmacy should have been in the file.