Dignity Health, Mercy San Juan Medical Ctr – Pharmacy Upgrade to USP 797


Acute Care Hospitals, Pharmacies


Carmichael, CA


$1.6 Million


December 2021

Strict Timelines With Minimal Disruption

This project required close coordination with the Pharmacy, hospital leadership, HCAI, licensing consultants, CDPH, Board of Pharmacy, as well as other construction projects occurring simultaneously in the same building.  Licensing and Board of Pharmacy played a vital role twice in this project. Strict timelines were enforced for notifications to the agencies, as well as timely completion of construction once notifications were issued.

24/7 Inpatient Pharmacy Agency Coordination

The Stahl Companies oversaw the complete renovation of the Pharmacy at Mercy San Juan from conceptual planning through occupancy. The remodel included the IV Prep, Chemo Prep, and Ante Room spaces to meet current USP 797 and 800 requirements.

The work occurred in a functioning hospital pharmacy which required extensive logistics and transition planning to facilitate a phased-occupancy approach – this was required to allow the pharmacy to remain functional during construction. This project required a complete understanding of the Pharmacy’s hazardous and non-hazardous compounding environment to ensure the department was adhering to the broad set of newly enforced requirements.

Two new dedicated exhausts were added along with a new Chemo Prep hood.  Various other pieces of equipment, including pharmacy-grade refrigerators, pass-through windows, scrub sinks, shelving, and workstations were replaced.  Staff dressing was expanded, and the donning/doffing areas were modified.

The Stahl Companies worked hand-in-hand with multiple municipalities including CDPH, Board of Pharmacy, and local Fire to obtain sign-off for final use. Once completed, the compounding spaces were opened for the users, allowing them to compound in-house. This is a huge operational benefit as it will mitigate the use of a courier service to transport drugs from the surrounding Common Spirit hospitals.

At the Mercy San Juan Campus, construction within their existing Pharmacy is now complete, and we are excited to announce that we have recently received Substantial Compliance from HCAI.

We are grateful for the lessons learned, relationships built, and continued teamwork and collaboration with our partners at Common Spirit.