Is your ambulatory care facility ready for survey? Ok, ok: that’s probably a rhetorical question as you never feel truly ready, right? Though surveys are routine events for facilities, they can still be unnerving. No matter how prepared you may be, it’s only human to become a bit anxious when faced with an unannounced ‘pop quiz’.

A Consultant Pharmacist’s Top 10 Tips for Ensuring Survey Success: Part 1

Is your ambulatory care facility ready for survey? Ok, ok: that’s probably a rhetorical question as you never feel truly ready, right? Though surveys are routine events for facilities, they can still be unnerving. No matter how prepared you may be, it’s only human to become a bit anxious when faced with an unannounced ‘pop quiz’.

As a consultant pharmacist who routinely works with ambulatory healthcare facilities to ensure survey-readiness, I know what needs to be done to ensure compliance. Drawing upon my experience, I’ve compiled a list of key items to check off so that when survey day does arrive, you can rest a bit easier.

In this post, the first in my two-part series on survey success, I’ll focus on how to ensure your documentation and medication storage are ready for your next survey.

10 Documentation & Medication Storage Items to Check Off for Survey Success

  1. Cart organization: All anesthesia, nursing, and code carts should be organized for easy access and patient safety.
  2. Separation of medications: Always store medication to minimize risks: this is especially important for medications that look-alike and sound-alike.  Use physical separation and appropriate labeling.
  3. Syringe labeling: Follow the guidelines for appropriate labeling of all pre-drawn syringes.  Although CMS clearly specifies the required elements, as do the accrediting agencies, such as the Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC), I often find that the timing (preparation and expiration) and initials of the preparer as common missing elements.
  4. Storage temperature: Store all medications at the manufacturer’s recommended temperature.  Some medications can stay at room temperature; some require refrigeration and others may be stored in the refrigerator until they are placed in the carts for use.  When placed in the cart, they are left at room temperature for the remainder of their viable usable time: pay close attention to the shortened beyond-use-date on these products and always label them accordingly.
  5. Medication security: All medications should be secured when unattended.  This includes all cabinets and carts.  Additionally, carts containing controlled medications must be double-locked.
  6. Anesthesia documentation: All records should be legible, including anesthesia documentation.  Dosing should be explicitly documented, including the tally of each dose, along with clearly noted total dosing.
  7. Expiration dates: Develop and implement a system to check for expirations on a monthly basis (at least).  This process should involve a rotating schedule that encourages everyone to have familiarity with the contents of the carts.  Remember that expirations apply to medical supplies and instruments, not just medications.
  8. Medication reconciliation: Review your reconciliation process and continually work to update policy and procedures so as to establish a safe practice when providing guidance to patients on discharge.
  9. Allergy documentation: Properly document all noted allergies in a prominent and consistent location.  Be certain to consistently document the associated reaction to further clarify the noted allergy.
  10. Malignant hyperthermia: Success here starts with following the guidance provided by the Malignant Hyperthermia Association of the United States (MHAUS) and making sure your cart contents are up-to-date.  Having all the necessary supplies is the first step, but knowing how to use them is just as important.

In next week’s post, we’ll address the importance of medication labeling and administration for survey success. If your ambulatory facility needs help achieving compliance, or if you have questions about the first ten items, our pharmacy consultant services can help: please don’t hesitate to contact us.

 


The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centerssenior care facilities and pharmacies  We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.


 

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