Volume 2024 | No. 2
SURVEYOR
PHARMACY
SECTION 5: PROVISION OF CARE & RECORD MANAGEMENT DRX5-1A
DRX5-2B
Overview of the requirement:
Prior to the initiation of care/service, a pharmacist, RN, or other qualified professional conducts an initial evaluation/assessment of the client/patient. Seven elements are required: demographics, physical health component, social component, environmental component, economic component, functional limitations, and mental component. Ambulatory Infusion, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Specialty Pharmacy with or without DME Compliance is assessed by reviewing the client/patient record and through observation. Most organizations conducted an initial assessment. The majority of deficiencies resulted from missing components of the assessment and lack of documentation in the patient record.
Overview of the requirement:
Written policies and procedures are established and implemented relating to the required content of the client/patient record. An accurate record is maintained for each client/patient. The content of the client/patient record contains several required elements. Ambulatory Infusion, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Specialty Pharmacy with or without DME Compliance is assessed through review of both written policies and procedures and client/patient records. Several deficiencies cited incomplete client/patient records. The most common missing elements of the client/patient record were the emergency contact and documented initial/ongoing assessments.
Applicable services:
Applicable services:
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
17%
Frequency of citation:
13%
Examples of surveyor findings:
n Audit patient records to ensure all required elements are being documented in the initial assessment. n Patient records did not contain documentation of: ٝ Medication profile, including other prescription medications, OTCs, and herbals. Other medical diagnoses and pertinent medical history. Non-drug related allergies/sensitivities. n Although patient demographics and certain aspects of physical health are documented, there was a lack of evidence indicating the clinician reviewed other pertinent diagnoses, social components, and mental components, specifically in the areas of orientation/memory and reasoning/ judgment. n Patent records were missing an evaluation of the environmental component (safety or health hazards, presence of adequate living arrangements, etc.). n Implement a process to ensure all medications (prescription, premeds, over- the-counter, etc.) are included in the patient medication profile. Include name, strength, frequency, etc. n Include all limitations and barriers in the initial assessment. Specifically, evaluate mental components that may impact drug adherence. Based on the assessment findings, plan and implement interventions that address identified mental health issues. n Document an answer to all questions to ensure they have been asked, regardless of the answer: If the patient declines to give an emergency contact, state “patient declined.”
Examples of surveyor findings:
n Client/patient records did not contain: Emergency contact information.
.Signed HIPAA and admission/informed consent documents or emergency contact listed or refused. .Initial assessment and/or ongoing assessment. .Diagnosis. .Admission and informed consent documents. .Signed notice of receipt of Client/Patient Rights and Responsibilities. n Patient records revealed inconsistencies between the physician orders, the pharmacy label, and the nursing plan of treatment. n Ensure all patients have signed admission and informed consent documents as part of the client record. n Obtain an emergency contact for all patients. Document if the patient refuses to provide emergency contact information. n Complete and document an initial assessment on all new clients/patients admitted for service. n When auditing client/patient records, verify all orders are being dispensed, prescription labels, and plan of treatments match the prescriber’s order.
Tips for compliance:
Tips for compliance:
Consider establishing a process to track and manage reassessments effectively. This can be achieved by implementing reminders or notifications that alert the pharmacist when a reassessment is due.
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