In response to inquiries from a number of hospitals, the Department has determined that regulations at 105 CMR 722.000 permit inpatients of a hospital's satellite clinic, located within a second host hospital, to be considered inpatients of the host hospital for the purposes of delivery of pharmaceutical services only.

Following is a list of commonly asked questions in which a hospital (host hospital) wishes to fill medication orders for inpatients of another hospital's satellite clinic, that is located within the host hospital.

Is it permissible for the host hospital to provide pharmaceutical services to inpatients of another hospital's satellite clinic located within the host hospital?
Yes. The Department has no objection to a hospital providing pharmaceutical services to inpatients of another hospital's satellite clinic, located within the host hospital. Such activity is consistent with the regulatory intent of 105 CMR 722.000. The satellite clinic must be listed on its hospital's license, with the same address as that of the host hospital.

Does the Department view these patients to be those of the host hospital or the satellite clinic?
Inpatients of the satellite clinic may be considered to be patients of the host hospital for the purposes of pharmaceutical care. This is similar to those instances in which inpatients of a hospital-based skilled nursing facility are serviced by a hospital pharmacy. In such cases, the Department considers the SNF patients to be those of the hospital for the purposes of the provision of pharmaceutical care.

Are additional Massachusetts and U.S. Drug Enforcement Administration Controlled Substances Registrations required at the satellite clinic if the host hospital is providing pharmaceutical care?
No. Since the Department considers inpatients of the satellite clinic in this instance to be patients of the host hospital for the purposes of pharmaceutical care, the Massachusetts and U.S. Drug Enforcement Administration Controlled Substances Registrations of the host hospital apply and additional registrations are not required, provided the satellite clinic is located at the same address as the host hospital.

Is the host hospital required to maintain a separate inventory for the satellite clinic?
No. Since, in this case, inpatients of the satellite clinic are considered to be patients of the host hospital for the purposes of pharmaceutical services, a separate inventory for controlled substances is not required. The satellite clinic must maintain the same accountability system for controlled substances as that of the host hospital.

If the host hospital and the satellite clinic have operated independently and a decision is made to permit the host hospital to provide pharmaceutical services to inpatients of the satellite clinic, is it permissible for the host hospital to purchase the unused inventory of the satellite clinic?
Yes. The Department permits the transfer of inventory, provided that a written proposal is submitted to the Drug Control Program 14 days in advance of the transfer. Included in the proposal must be a complete inventory of all opened and un-opened containers of all controlled substances (Schedules II-VI), and the disposition of all outdated controlled substances (Schedules II-VI), that must be agreed to by both hospitals. The host hospital must accept the liability for the integrity of controlled substances secured from those of the satellite clinic.

Must the satellite clinic receiving pharmaceutical services from the host hospital adhere to the policies and procedures of the host hospital relative to accountability of controlled substances?
Since, in this instance, the Department considers inpatients of the satellite clinic to be patients of the host hospital for the purposes of pharmaceutical care, policies and procedures of the host hospital must be followed.

What types of documentation does the Department recommend be established between the satellite clinic and the host hospital?
The Department recommends, at a minimum, that the host hospital and the satellite clinic develop a written agreement to ensure effective communication between the facilities as to administration of controlled substances, in which the following is included:

  • Description of the method by which the dispensing by the host hospital will occur, including policies and procedures for the administration of controlled substances by all staff;
  • Description of the method in which patient records of the satellite clinic and those of the host hospital will be integrated to assure drug utilization review prior to administration; and
  • Description of the manner in which the host hospital will notify appropriate staff of the satellite clinic of any medication error or other adverse outcome to patients of the satellite clinic.

For further information contact the Drug Control Program at (617) 983-6700.


This information is provided by the Drug Control Program within the Department of Public Health.