Volume 2025 | No. 2
SURVEYOR
PHARMACY
Compliance tips for:
Examples of ACHC Surveyor findings: ■ Patient records reviewed contained an initial assessment. However, these assessments lacked evidence of addressing environmental components (safety or health hazards, presence of adequate living arrangements, etc.), functional limitations, and social and mental health/cognition concerns. ■ Patient records did not contain documentation of: ٝ Evaluation of relevant non-drug substances, including allergies/sensitivities.
■ Employee education must continue after orientation. The standard lists the required topics, but the organization defines how these topics are presented. ■ Education activities should incorporate a variety of learning methods including journals, reference materials, books, internet resources, in-house lectures, demonstrations, conferences, and courses. ■ Create a checklist for all required topics. Audit personnel files for documentation that each requirement is met. ■ Implement an attendance log for training sessions. ■ Establish recurring dates for ongoing education. Set calendar reminders. ■ The most common missing training topic is client/patient rights and responsibilities. Consider interviewing personnel to see if they can identify some client/patient rights and responsibilities during mock surveys. ■ Track initial/ongoing education as part of your PI activities. ■ Assess your organization’s current education methods. Are they effective? Is the information being retained? If education efforts are missing the mark, consider creative solutions such as trivia questions, “spot the deficiency” slides, or flashcards.
Nerd Newbies (understand the requirement)
ٝ An emergency contact (or documentation that one is not available). ٝ Allergies and /or sensitivities to drugs listed on physician's documents. ٝ Other medical diagnoses and pertinent medical history. ٝ Medication profile, including other prescription medications, OTCs, and herbals.
Nerd Apprentices (audit for excellence)
Compliance tips for:
Nerd Trailblazers (prepare the path for others)
■ Per state licensure rules or regulations, a pharmacist, registered nurse, or other qualified professional conducts an initial evaluation/assessment to determine eligibility, care, and support needs of the client/patient. The evaluation/assessment is documented whether services continue or not. ■ The standard details seven required components of the initial assessment. Positive client/patient outcomes hinge on understanding and addressing all seven components of the initial assessment. Is the home environment safe? Are financial resources adequate? Does the client/patient have mental/cognitive issues? ■ Review and update all current and new client/patient records for missing information. ■ Develop and implement a template/form for conducting the initial assessment that contains the seven required components. ■ Ensure that intake forms/templates allow for “N/A” and declination of response. ■ Educate staff on the importance of the initial assessment as a key to client/ patient outcomes. ■ Conduct client/patient record audits and track missing information as a PI indicator. Present findings to the PI committee. ■ If using software, research whether the system can automatically flag missing information and produce warnings for selecting medications or supplies for which the patient has a documented contraindication (e.g., latex-allergy).
Nerd Newbies (understand the requirement)
SECTION 5: PROVISION OF CARE & RECORD MANAGEMENT D RX5-2B Applicable services: Ambulatory Infusion, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Specialty Pharmacy with or without DME
Nerd Apprentices (audit for excellence)
Frequency of the citation: 15%
Nerd Trailblazers (prepare the path for others)
Overview of the requirement: Prior to the initiation of care/service, all clients/patients receive an evaluation/assessment of their needs. Seven elements are required: demographics; functional limitations; and physical health, social, environmental, economic, and mental components. Comment on deficiencies: Compliance is assessed through observation and by reviewing the client/patient record. The majority of deficiencies resulted from missing components within the assessment.
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