Drug shortages are still coming up quite frequently in facilities. Is your policy and procedure describing what to do when you have a drug shortage up to date? Do you follow the steps noted in your policy? Is your consultant pharmacist helping by providing you with updated regulatory guidance?

Are your policies and procedures up to date?

Drug shortages are still coming up quite frequently in facilities.   Is your policy and procedure describing what to do when you have a drug shortage up to date? Do you follow the steps noted in your policy? Is your consultant pharmacist helping by providing you with updated regulatory guidance?

A few months ago when I spoke at the 7th annual Northeast ASC Conference, I talked about how one of the most common deficiencies during surveys is the lack of policies and procedures/ not following policies and procedures as written.

What steps can you take?

As part of your continued January resolution of avoiding poor survey outcomes, here are two simple steps you can take that will make a difference during your next survey:

1) Review policies and procedures to ensure they are up to date; and

2) Confirm you are following what is written down.

One of the first things a surveyor will ask for are your policies and procedures. If you do not have a required policy, this may be indicative of a deficient practice that will likely lead to a citation.  Additionally, your policies also need to be tailored to your circumstances AND once tailored, you need to follow them.

Not following your own policies is like a “yellow brick road” to deficiencies for surveyors.   Take the time to review these documents throughout the year to make sure they are up to date.

As a surveyor once told me, facilities claim they don’t have money in the budget to do it right from the beginning, but they always find money in the budget to fix it later.  Take the time to do it right from the start and if you need assistance with updating a policy or have a question about whether a certain regulation applies to you, contact us for additional guidance.


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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