The permit holder shall: Develop and maintain a policy and procedure manual which establishes the pharmacy’s policies and standard operating procedures related to the provision of infusion therapy services; Ensure that an annual review of the policy and procedure manual is performed by a qualified clinician or clinicians to assure that the policies and procedures meet the current standards of practice and regulatory requirements; Ensure that there is a process to verify the name, address, and contact information of the licensed authorized prescriber of record before initiation of therapy; Establish and maintain a training program which includes, but is not limited to, the requirements set forth in Regulation .07 of this chapter; If the infusion pharmacy is performing sterile compounding, ensure compliance with COMAR 10.34.19; If the infusion pharmacy outsources sterile compounding to another pharmacy, confirm that the secondary pharmacy is appropriately licensed and in compliance with COMAR 10.34.04 and COMAR 10.34.19; Assign a supervising pharmacist to provide oversight of the facility and operations as specified in Regulation .03 of this chapter; Ensure adequate supervision to unlicensed personnel; Limit access to the infusion pharmacy area to authorized personnel; Secure the facility and patient records in compliance with federal and State laws and regulations; and Develop and implement a written performance improvement program as set forth in Regulation .08 of this chapter.