Volume 2025 | No. 2
SURVEYOR
PHARMACY
SECTION 4: HUMAN RESOURCE MANAGEMENT DRX4-8 A Applicable services: Ambulatory Infusion, Community Retail, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Specialty Pharmacy with or without DME
PHARMACY SERVICES AND DISTINCTIONS
Frequency of the citation: 16%
Services
Distinctions
Overview of the requirement: A written education plan is developed and implemented that defines the content and frequency of evaluations. The plan includes training provided during orientation as well as ongoing in-service training for each classification of personnel. Note: For pharmacies that receive ACHC Community Retail Accreditation, this standard only applies to personnel who provide Community Retail-accredited DMEPOS product codes. Comment on deficiencies: Compliance is evaluated through staff interviews and review of policies, procedures, and training/in- service logs. Deficiencies resulted from gaps in education documentation. The most common issue was lack of ongoing, annual training. Examples of ACHC Surveyor findings: ■ Personnel files did not contain evidence of completion of the following required annual training: ٝ Client/patient rights and responsibilities. ٝ Communication barriers. ٝ How to handle grievances/complaints. ٝ Ethics training. ٝ Infection control training. ٝ Emergency/disaster training. ■ Employees did not have evidence of completion of any annual training. There was evidence that
Ambulatory Infusion Center/Suite Community Retail Hazardous Drug Handling* Infusion Nursing Infusion Pharmacy Infusion Pharmacy without Sterile Compounding
Long-Term Care Pharmacy Mail Order Pharmacy Specialty Pharmacy Specialty Pharmacy without DMEPOS
Infectious Disease Specific to HIV Nutrition Support Oncology Rare Diseases and Orphan Drugs
*Not a stand-alone service. Available for pharmacies seeking or renewing Infusion Pharmacy Accreditation.
FREQUENT DEFICIENCIES IN PHARMACIES
60%
50%
40%
30%
the training was conducted, but a list of employees in attendance was not available. ■ Required topics are only addressed in orientation training, not annual training.
20%
10%
0%
DRX4-8A
DRX5-2B
DRX5-2C
DRX5-4A
DRX7-1D
DRX7-9A
Provision of Care and Record Management
Human Resource Management
Risk Management: Infection and Safety Control
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