Volume 2025 | No. 2
SURVEYOR
PHARMACY
DRX5-4A Applicable services: Ambulatory Infusion, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Specialty Pharmacy with or without DME
SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL DR X7-1D Applicable services: Ambulatory Infusion, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Specialty Pharmacy with or without DME
Frequency of the citation: 15%
Overview of the requirement: The organization must have evidence of client/patient participation in the plan of care/service. Comment on deficiencies: Compliance is assessed through staff interviews and review of client/patient records. Deficiencies were cited for lack of signatures and/or notations. Most organizations discuss the care/service plan with clients/patients, but they omit the step that documents review and approval. Examples of ACHC Surveyor findings: ■ Client/patient records did not have a plan of care therefore no evidence of patient participation in the plan of care. ■ Client/patient records did not have evidence of client/patient participation in the plan of service/care. Compliance tips for:
Frequency of the citation: 15%
Overview of the requirement: The organization monitors infection statistics (e.g., upper respiratory infection, stomach virus, influenza, COVID, etc.) of both clients/patients and personnel. Data are tracked and trended, then subsequently used to assess the effectiveness of the organization’s infection control practices. Performance improvement reports with data and action plans are shared with both personnel and leadership. Comment on deficiencies: Surveyors assess compliance by reviewing performance improvement reports, as well as infection tracking records and logs. Most surveyed organizations are conducting some measure of monitoring of staff and clients/patients for infections. Deficiencies are cited for partial compliance. Examples include lack of documentation, documentation without data analysis or data trending, and/oror tracking without reporting the findings into the PI program. Examples of ACHC Surveyor findings: ■ Organization has a process in place to document infections for both patients and personnel. However, there is no evidence of tracking these infections. ■ The organization tracks infections, but the PI coordinator does not use the data in the PI Program. ■ The organization has infection control log templates, but the log presented was blank. ■ The organization is monitoring infection statistics for clients/patients, but not for personnel. ■ An ongoing PI activity to monitor infections has not been included in the PI reports.
■ The client/patient has a right to be involved in the development of the plan of care/service and any changes in that plan. ■ The degree of involvement may vary depending on the status of the client/ patient. At a minimum, the client/patient agrees to the plan of care/service prior to the beginning of services and as subsequent changes occur. ■ Implement a plan for documenting client/patient participation in the plan of care/service. Methods used to document participation include, but are not limited to: ٝ Client/patient signature. ٝ A notation in the client/patient record that the patient participated in the development of the plan of care. ٝ A notation in the client/patient record that the plan of care was reviewed and accepted by the patient. ■ Evaluate paperwork, templates, and/or software used to capture the plan of care/service. Does the method used allow for the documentation of client/ patient participation? Revise as necessary. ■ Retrain staff to remain vigilant about capturing this information. ■ As part of the care plan record audit mentioned above for standard DRX5-2C, include tracking for the client’s/patient’s participation in the care plan process. Incorporate findings into the PI program.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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