Volume 2024 | No. 2
SURVEYOR
PHARMACY
If patient does not have any functional limitations, then state “no functional limitations.” If there are no known allergies, document NKA (no known allergies). When using software, consider documenting allergies in a consistent location within the dispensing program. This will allow the system to effectively capture all interactions and prevent potential oversight. Check if the pharmacy software system can automatically flag and produce warnings if allergy-inducing supplies are selected during patient care. This includes, but is not limited to, latex, Iodine, adhesives/tapes, and other substances that may be used for infusion services. There is a written plan of care for each client/patient accepted for care/services. The plan of care is developed during the initial evaluation/assessment and is directed toward driving positive client/patient outcomes. Ambulatory Infusion, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Specialty Pharmacy with or without DME Surveyors review client/patient records and policies and procedures to evaluate compliance with the care plan process. Deficiencies noted the absence of a care plan, and when a care plan was present, it was not patient-specific and lacked therapy goals and outcomes.
Tips for compliance:
n Qualified personnel should develop care plans that encompass individualized therapy goals, recognized problems, interventions, and monitoring. All care is delivered in accordance with the written care plan. n Train personnel that all fields in templates must be completed. n Provide education on disease management and care planning to patients/ caregivers. n Review processes with staff to ensure that all patients have a documented goal of therapy. Consider auditing compliance as part of chart reviews in PI program. n Establish a monitoring plan to track progress towards achieving the expected patient outcomes. n Ensure the plan of care includes patient-specific goals that are directed toward driving positive outcomes and provide evidence of patient participation.
DRX5-2C Overview of the requirement:
SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL DRX7-5B
Applicable services:
Overview of the requirement:
Written policies and procedures are established and implemented that address the organization’s fire safety and emergency power systems. Ambulatory Infusion, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Mail Order Pharmacy, Specialty Pharmacy with or without DME Compliance is assessed through observation and review of policies and procedures. Deficiencies most often reflected improper fire extinguisher maintenance and missing fire drill documentation.
Comment on deficiencies:
Applicable services:
Frequency of citation:
15%
Comment on deficiencies:
Examples of surveyor findings:
n Client/patient records failed to show evidence of a written plan of care. n Although staff could vocalize appropriate goals for patients, the goals of therapy are not being documented. n Care plans were present in the patient records; however, the care plans were missing components. ٝ Care plans were not tailored to each patient’s needs identified during initial assessments. There was no documentation of interventions within the plan of care. Plans lacked documentation of problems, goals, interventions, and monitoring plans n Although this site does not provide documentation of patient therapy goals/ outcomes, it is part of their patient records and should be documented by nursing or by remote pharmacist providing clinical monitoring. n It was noted that the care plans contained considerable free typing, which led to inconsistencies and missing critical information.
Frequency of citation:
12%
Examples of surveyor findings:
n Written procedures regarding fire safety do not include: Providing emergency power to critical areas. Testing of emergency power systems (at least annually).
ٝ Maintenance of smoke detectors, fire alarms, and fire extinguishers.
n Fire drills have not been performed to determine if the emergency preparedness plan needs any improvement. n Annual fire drills have been completed; however, there was no documented evaluation of the drill. n There was no illuminated exit sign within the pharmacy. One exit sign at the back of the pharmacy suite was blocked, so the line-of-sight to the exit sign was not clearly visible.
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