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FAQs on After-Hours & On-Call Services

Pharmacies serving long-term care patients must meet CMS standards by ensuring 24/7 access to a licensed pharmacist. This can be achieved through in-house rotations, third-party services, or partnerships, as long as calls are triaged promptly—ideally within 15–30 minutes—and documented. Compliance requires clear policies, call logs, and reliable emergency medication access. Common pitfalls include relying only on voicemail, poor documentation, and delayed responses. The goal is simple: patients and providers must always have timely pharmacist support beyond business hours.

 

 

LTC@H Pharmacy Network 

FAQs on After-Hours & On-Call Services

Does CMS require pharmacies to provide 24/7 access to a pharmacist?
  • Yes. Under CMS Conditions of Participation (CoPs) and LTC pharmacy service standards, a pharmacy serving long-term care patients must ensure 24-hour, 7-day-a-week access to a licensed pharmacist for consultation on medications, clinical issues, and emergency supply needs.
What counts as an acceptable “after-hours answering service”?

An acceptable service must:

  • Allow a prescriber, nurse, or caregiver to reach a pharmacist directly or via an operator.
  • Provide timely triage to a licensed pharmacist (not just a voicemail box).
  • Ensure patients have access to urgent medication and clinical guidance.

Can pharmacies use a third-party answering service?

  • Yes. Many pharmacies contract with HIPAA-compliant third-party answering services. The key is that the service must reliably connect callers with an on-call pharmacist within a reasonable timeframe (typically 15–30 minutes).

How quickly must a pharmacist respond to an after-hours call?

  • CMS does not specify an exact number of minutes, but industry best practice is a 15–30-minute call-back window. Documented responsiveness is critical for compliance and for protecting patient safety.
What if the on-call pharmacist cannot resolve the issue immediately?

The pharmacist must:

  • Provide interim clinical guidance.
  • Document the interaction.
  • Ensure delivery or access to emergency medications through an established process (e.g., E-kits, courier service, backup pharmacy partner).
Do independent pharmacies have to staff their own 24/7 line?

Not necessarily. Options include:

  • Rotating on-call responsibilities among staff pharmacists.
  • Contracting with a third-party clinical call center.
  • Partnering with another LTC pharmacy for shared coverage.

The important part is documenting the system and ensuring patients are never without pharmacist access.

How do pharmacies prove compliance with CMS standards?

Documentation is key. Pharmacies should maintain:

  • A written policy on after-hours coverage.
  • Logs of calls received and responses.
  • Contracts or agreements with answering services or backup pharmacies.
  • Records of pharmacist interventions made outside normal business hours.
What are common pitfalls that lead to non-compliance?
  • Using only a voicemail system with no guaranteed pharmacist call-back.
  • Failing to maintain call logs or documentation.
  • Delays in response that compromise patient safety.
  • Not training staff on how to route urgent calls after-hours.

How can LTC@H Pharmacy Network help with meeting this standard?

The Network provides:

  • Education on CMS requirements and best practices.

  • Sample policies, procedures, and documentation templates.

  • Guidance on choosing answering services or creating an in-house on-call program.

  • Peer examples of compliant systems.