Volume 2024 | No. 2
SURVEYOR
PHARMACY
SECTION 1: ORGANIZATION AND ADMINISTRATION DRX1-4A
SECTION 2: PROGRAM/SERVICE OPERATIONS DRX2-4C
Overview of the requirement:
There is an individual who is designated as the manager/leader responsible for the overall operation and services of the organization. Another individual is authorized, in writing, to act as the manager/leader in the absence of the manager/leader. Ambulatory Infusion, Community Retail, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Mail Order Pharmacy, Specialty Pharmacy with or without DME Compliance is evaluated through direct observation and review of personnel files. Most deficiencies were related to the appointment and job description of the temporary/alternate leader.
Overview of the requirement:
At the time of admission, patients are provided with written information regarding how to contact the organization, relevant state agencies, and ACHC with grievances/complaints about the care/services they receive. Ambulatory Infusion, Community Retail, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Mail Order Pharmacy, Specialty Pharmacy with or without DME Admission packet and patient record reviews are used to validate compliance. Deficiencies noted a lack of documentation of patient/client receipt as well as missing content from the admission packet itself. In several cases, information for the state BOP was not listed.
Applicable services:
Applicable services:
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
12%
Frequency of citation:
13%
Examples of surveyor findings:
n A temporary leader has not been appointed to act in the absence of the leader. n The duties of the temporary leader were not included in the job description. n There was a statement in the job description for the PIC, but the duties of the PIC as the temporary leader were not included in the appropriate job description. n Although the job description addendum for a temporary leader was available, the form was not filled out including the name of the temporary leader and the required signature. n There was no application or resume of the alternate manager/leader verifying the education and experience required for the position. n Authorize, in writing, an individual to act as the temporary leader. n Add the duties of the temporary leader to the appropriate job description or create a job description specific to the temporary leader and have it reviewed by the appropriate individual. n Designate, in writing, an onsite alternate administrator with the responsibility and authority for the daily operation of the agency during absence of the administrator. n Document evidence to support that the alternate manager/leader is qualified for the position.
Examples of surveyor findings:
n The organization’s new patient packet did not contain:
ٝ . The name or position of a contact person to reach out to voice a grievance or complaint. ACHC’s telephone number (once accredited). .The organization’s process for receiving, investigating, and resolving grievances/complaints about its care/service. The appropriate state regulatory body’s hotline telephone number. о Site is dispensing to Georgia residents, but the Georgia BOP contact info is not provided. о The contact information for the NY Board of Pharmacy is missing. о There was no evidence that the patient was provided information required by Florida AHCA regulations. о The telephone number of the Louisiana Board of Pharmacy (BOP) was not included.
Tips for compliance:
n Patient/client records did not have documentation of receipt of: New patient welcome packet.
.Information about the organization’s process for receiving, investigating and resolving grievances/complaints about its care/service.
achc.org | (855) 937-2242 | 25
24
Made with FlippingBook Digital Proposal Creator