Our Christmas Wish list is succinct this year. After enduring nearly two years on the COVID-19 rollercoaster, we have become more grateful for the more modest things in life. This week we are discussing simple things facilities can ask Santa for, that would make surveys easier. What’s on your list?

We know the list of “wishes” facilities have is extremely long. Starting with wanting things to go back to pre-COVID-19 normalcy, mask wearing to go away, staffing to be at full capacity, PPE to be readily available, no drug shortages, and we could go on and on. Instead, let’s focus on a few more controllable items we can wish for and get this holiday season.

Three items that would reduce survey deficiencies:

1. Proper labeling of pre-drawn syringes: Many facilities get cited for issues related to labeling of pre-drawn syringes. This is a common deficiency because there are so many opportunities for error. Proper medication administration includes adequately labeling. Pre-drawn syringes are pretty commonly used by the anesthesia team and present a challenge in a busy environment. Do you know the required elements of a complete label? We provide our clients with a reference card that easily allows them to determine compliance. If you don’t have one, let us know. It’s a great reference and provides quick guidance to ensure all elements are present. Although compliance with this standard requires effort, it’s an easy thing to ask for and receive…not just for the holidays, but all year long.
2. Monitoring and logging refrigerator temperatures: Like the other items on this list, this is an easy ask and compliance doesn’t take much effort, but it does take a system. You’d be surprised at how often facilities get cited for items that are easy to comply with. Why? Because when a system is not in place, there is no consistency. Lack of consistency leads to deficiencies. So, what does Santa need to bring you to be compliant? Develop a system of daily refrigerator temperature monitoring and documentation. The most successful facilities have this one on cruise control. There is someone assigned to this task, and they have an easy-to-use log for their daily temperature checks. Here are a couple of tips to help you ace this part of your survey: First, make sure you are using an approved thermometer. Preferably one that tracks temperatures over time and alarms/notifies when temperatures are above or below the normal limits. Second, remember that the Centers for Disease Control and Prevention (CDC) has strict requirements for temperature monitoring. You can achieve compliance several ways. Work with your pharmacy consultant to choose the most effective way for your facility. If you don’t have a pharmacy consultant and need help, reach out and we would be happy to guide you.
3. Prominently and consistently documenting patient allergies: As I recently wrote in a post titled “Documenting Patient Allergies”, documenting patient allergies is not only an expectation of surveyors, it’s a critical patient safety function. The expectation that facilities ask patients about all allergies and sensitivities and then document them clearly, is consistent across licensing and accrediting organizations such as the Centers for Medicare and Medicaid Services (CMS), Accreditation Association for Ambulatory Health Care (AAAHC), The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) and The Joint Commission (TJC). The patient’s medical record should show evidence that the patient was asked to provide information about allergies and sensitivities at each encounter and those allergies/reactions should be documented consistently and prominently. If you don’t already have one, develop a process and teach your staff to repeat the same steps for each patient. A good tip is to determine where you want the allergies documented and then add an additional space to document the actual reaction. Doing this consistently will go a long way to avoiding survey deficiencies.

These three items are easy asks this holiday season and despite being easy tasks, they can go a long way to making your next survey a much more festive occasion. If you have questions on these items or other items that come up frequently on surveys, don’t hesitate to reach out to us.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior 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.