Volume 2024 | No. 2
SURVEYOR
PHARMACY
Tips for compliance:
n Update the policy concerning the patient complaint and grievance process to ensure it includes all contents required by ACHC standards. n Once accredited, add ACHC’s phone number to written documentation in the event the client/patient does not have access to the website or requests a written copy. n Audit state regulations for required language and current agency/pharmacy board contact information. Reeducate personnel on the contents of the new patient packet and how they are to document providing this information to the client/patient at the start of care. Implement a consistent process for documenting proof of receipt by the client/patient of the new patient packet (e.g., include it on delivery tickets as a start of care line item).
n The personnel records lacked documentation of an initial competency assessment upon hire, annually, and prior to personnel performing a new task. n Personnel files reviewed did not contain documentation of training and competency assessments for infusion pumps. n Current competency assessments for pharmacists and technicians were identical and did not include a specific focus on the pharmacist’s role in educating patients on specialty drugs. n Personnel records reviewed showed competency assessments completed solely using self-assessments. n Complete and maintain documentation of a competency assessment completed upon hire, annually, and prior to personnel performing a new task. n Develop a process that encompasses all required elements, including frequency and methods. Note that self-assessment alone is not acceptable. Peer review of clinical personnel competency by like disciplines is acceptable if defined by the organization. n Ensure that the assessment of skills is specific to the employee’s role and job responsibilities: Address the unique responsibilities of pharmacists, including educating patients on specialty drugs. Distinguish these responsibilities from non- clinical staff. Conduct assessments for all ambulatory infusion nurses to ensure they are proficient in the essential topics and procedures. Consider utilizing a course to assess pharmacists’ knowledge of disease states pertinent to the pharmacy’s specialties. Ensure comprehensive coverage of the nurse’s role in providing infusion therapies. Your nursing competency form should include essential topics such as various line care and maintenance, infusion procedures, administration of various infusion drugs, drug education, and counseling for patients based on different therapy types.
Tips for compliance:
SECTION 4: HUMAN RESOURCE MANAGEMENT DRX4-7A
Overview of the requirement:
The organization must design a mandatory Competency Assessment Program for all personnel who set up, train, clean, test, repair, and/or educate on the use of medications, equipment, and/or supplies. n For pharmacies that receive ACHC Community Retail Accreditation, this standard only applies to personnel who provide Community Retail-accredited product codes. n Organizations accredited for Infusion Pharmacy with Sterile Compounding should refer to DRX4-7C for competency assessment requirements. Ambulatory Infusion, Community Retail, Infusion Nursing, Mail Order Pharmacy, Specialty Pharmacy with or without DME Compliance is evaluated through review of policies and procedures and documentation of ongoing competency assessments. Most deficiencies resulted from missing documentation of required competencies in individual personnel files. Assessment of skills must be specific to the employee’s role and responsibilities.
Applicable services:
Comment on deficiencies:
Frequency of citation:
15%
Examples of surveyor findings:
n Written policies and procedures did not address competency assessments that ensure personnel educating patients on the use of medications are competent to provide quality care related to the medications and disease states managed by the organization. n Written policies did not address the procedures required for the organization to design a Competency Assessment Program, which ensures that personnel educating patients on the use of medications are competent to provide quality care.
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