Volume 2025 | No. 2
SURVEYOR
PCAB (COMPOUNDING PHARMACY)
Compliance tips for:
A reasonable effort must be made to record the following in the client/patient record: ■ Identification data ■ Communication information ■ Date of birth ■ Gender ■ Name of prescriber ■ Prescribed drug(s) ■ Treatment diagnosis ■ Other patient medications, prescription and nonprescription ■ Other patient health conditions ■ Other relevant information, e.g., height and weight when applicable to the course of treatment ■ Allergies and /or sensitivities to drugs and/or relevant non-drug substances which may include: ٝ Peanuts. ٝ Soy. ٝ Latex. ٝ Shellfish. ٝ Adhesive/tapes. ٝ Disinfectants. ■ Audit intake forms and confirm they contain: ٝ Each element of the standard. ٝ The option to select “None” or “N/A.” ■ Implement a process to document clearly that a client/patient has declined/ refused to provide the information. ■ Develop a process within your pharmacy’s clinical/dispensing platform that: ٝ Highlights the key missing elements of the client/patient record. ٝ Alerts personnel that the information is missing and needs to be obtained. ■ Educate staff on the importance of addressing any highlighted missing items when communicating with the client/patient. ■ Create a process and timeline for follow-up when clients/patients do not provide the required information.
SECTION 5: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT TCRX5-F Frequency of the citation: 27% Overview of the requirement: Risks, including infections, communicable diseases, and all variances (incidents, accidents, and complaints/grievances), are tracked and trended at least quarterly as performance improvement (PI) activities. An action plan is created to decrease occurrences. Comment on deficiencies: This standard is evaluated using PI reports and incident/variance reports. In many cases, pieces of data were collected but not incorporated into a formal PI Program. Most deficiencies related to the frequency of PI reports, lack of corrective action plans, and insufficient data analysis.
Nerd Newbies (understand the requirement)
Examples of ACHC Surveyor findings:
■ The pharmacy lacks a formal PI plan. ■ The pharmacy lacked evidence of ongoing monitoring of processes that involve risks, including infections and communicable diseases for patients and staff. ■ The data is being collected, but: ٝ It is not placed in a PI report for an official trending or pattern. ٝ It is not reported monthly or annually.
ٝ No threshold or written plan of correction exists for ongoing studies. ٝ There was no quarterly PI report or communication of findings.
Nerd Apprentices (audit for excellence)
Compliance tips for:
■ PI data alone is not sufficient. Tracking, trending, analysis, and a plan of correction are required for a full assessment. ■ This standard applies to gathering and assessing data on a quarterly basis. Data are related to infections and communicable diseases, as well as a review of variances, including but not limited to:
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
ٝ Incidents. ٝ Accidents. ٝ Complaints/grievances.
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