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pharmacy
WELCOME ACHC Specialty Pharmacy Accreditation
Top Deficiencies
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pharmacy
GREG STOWELL Senior Manager, Education & Training
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ACHCU
Customer Centered
EDUCATION Workshops
Webinars Training
TRAINING ACHC Standards Gap Analysis
Compliance Audits Pre-Survey Prep
TOOLS Workbooks Readiness
Policy & Procedure Manuals Performance Improvement (PI)
Audit Tools
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LEARNING OBJECTIVES
§ Review the “Top” standard deficiencies found during survey (New and Renewal)
§ Look at standards that we get the most questions about
§ Look at the tools available to you to assist you in your preparation
§ Discuss the importance of logging into Customer Central
§ Discuss the role of your account advisor in helping you prepare for accreditation
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ACHC PROGRAMS AND SERVICES
Home Health AideMedical Social Services Occupational TherapyPhysical TherapySkilled NursingSpeech Therapy
Distinction in Behavioral HealthDistinction in Hazardous Drug Handling (Ref. USP <800>)
Distinction in Infectious Disease Specific to HIVDistinction in Nutrition SupportDistinction in OncologyDistinction in Palliative Care
home health
distinctions*
Hospice Inpatient CareHospice Care
hospice
Private Duty Aide Private Duty Companion/Homemaker Private Duty Infusion NursingPrivate Duty Nursing Private Duty Occupational TherapyPrivate Duty Physical Therapy Private Duty Speech TherapyPrivate Duty Social Work
private duty
Community RetailClinical Respiratory Care ServicesFitterHome/Durable Medical EquipmentMedical Supply ProviderComplex Rehabilitation and Assistive Technology Supplier
dmeposAmbulatory Infusion CenterInfusion NursingInfusion PharmacySpecialty Pharmacy
> SRX without DMEPOSLong Term Care Pharmacy PCAB Accreditation (A Service of ACHC)
> Non-Sterile Compounding (Ref. USP <795>)> Sterile Compounding (Ref. USP <797>)
ACHC Inspection Services (AIS)
pharmacy
Sleep Lab/CenterHome Sleep Testing
sleep
ACHC offers a variety of Behavioral Health services to suit your accreditation needs. Contact ACHC for details or visit achc.org for a complete listing of services available.
behavioral health
Convenient Care ClinicsRenal Dialysis Facilities
ambulatory care
*The provider must be accredited with ACHC to be eligible for a distinction service.
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Revised March 2019Total: 17,941
ak 51 hi
37pr 32
tx 1808
az 414
ca 1407
c0 401
ct 83
al 419
fl 1595
ga 587
ia 256
id 129
il 662
in 405
ks 189 ky
280
la 344
ri 23
ny 480
vt 19
md 339
mi 600
mn 314
mo 383
ms 217
ar 257
mt 72
nc 834
nd 54
ne 149
nh 65
nj 300oh
631
ok228
or 218
pa 617
sc 446
sd 61
tn 469
ut 111
va 543
wv 114
wa 351
wi 263wy
51
nv 148
me 57
ma 191
nm132
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ACHC PHARMACY ACCREDITATION § When would I need multiple accreditations?
§ Can they be done on the same survey?
§ Do I need DMEPOS accreditation?
§ What is different with an SRX without DMEPOS survey?
§ What are Distinction Programs?
*The provider must be accredited with ACHC to be eligible for a distinction service.
Pharmacy Services: Ambulatory Infusion Center Infusion Nursing Infusion Pharmacy Specialty Pharmacy
SRX without DMEPOS Long Term Care Pharmacy PCAB Accreditation
Non-Sterile Compounding (Ref. USP <795>) Sterile Compounding (Ref. USP <797>)
ACHC Inspection Services Distinctions*
Distinction in Oncology Distinction in Hazardous Drug Handling (Ref. USP <800>) Distinction in Infectious Disease Specific to HIV Distinction in Nutrition Support
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ACHC MISSION AND VALUES
Our Mission
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
Our Values
§ Committed to successful, collaborative relationships
§ Flexibility without compromising quality
§ Each employee is accountable for his or her contribution to providing the best possible experience
§ We will conduct ourselves in an ethical manner in everything we do
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Performance Improvement (PI) activities include satisfaction surveys.
The PI plan identifies the process for conducting satisfaction surveys for the following: client/patient, personnel, and referral sources.
• The most common deficiencies are satisfaction surveys of personnel and referral sources that are not completed
ACHC Standard DRX6-3C:
SPECIALTY PHARMACY TOP DEFICIENCIES
Section 6
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There is an annual Performance Improvement (PI) report written.
For Specialty Pharmacy services, there is an annual PI report that includes the components of Standard DRX6-1D and DRX6-1G.
• The most common deficiencies are that the PI summary is not completed annually or that it does not contain all required components (See next slide)
ACHC Standard DRX6-1D&G:
TOP STANDARD DEFICIENCIES
Section 6
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Standard DRX6-1G: For Specialty Pharmacy (SRX) services, there is an annual performance improvement (PI) report.
Number of SRX clients/patients receiving prescriptions
Number of SRX prescriptions dispensed
Number of SRX prescriptions dispensed per payer source
Number of SRX prescriptions dispensed incorrectly:
• Wrong client/patient
• Wrong drug
• Wrong address
• Wrong quantity
Average delivery time
Number of complaints received and the average resolution time
Call center metrics
Satisfaction survey rates as a percentage of clients/patients served
Section 6
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Performance Improvement (PI) activities include ongoing monitoring an important aspect of care, client/patient records, complaints, and of billing and coding errors.
• The most common deficiencies are that there is not an ongoing PI activity to monitor these areas or that data is collected but not monitored through the PI program
ACHC Standard DRX6-3B,D,E&G:
TOP STANDARD DEFICIENCIES
Section 6
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Each Performance Improvement (PI) activity or study contains the required items.
• A description of indicator(s) to be monitored/activities to be conducted
• Frequency of activities
• Designation of who is responsible for conducting the activities
• Methods of data collection
• Acceptable limits for findings or thresholds
• Who will receive the reports
• Written plan of correction when thresholds are not met
• Plans to re-evaluate if findings fail to meet acceptable limits
ACHC Standard DRX6-2A:
TOP STANDARD DEFICIENCIES
Section 6
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Each Performance Improvement (PI) activity or study contains the required items.
The organization has an established Compliance Program that provides guidance to the various internal anti-fraud and abuse controls. The guidelines include several items including performing internal audits to monitor compliance.
• The most common deficiency is not completing internal audits to monitor the compliance program or that the audits are not monitored through the PI program
ACHC Standard DRX2-9A:
TOP STANDARD DEFICIENCIES
Section 2
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A written education plan is developed and implemented that defines the content, frequency of evaluations, and amount of ongoing in-service training for each classification of personnel.
The education plan includes training provided during orientation and ongoing in-service education.
• The most common deficiencies are that none of the in-services are completed, that only some of them are completed, that they are not completed by all personnel, or they were completed but not documented
ACHC Standard DRX4-8A:
TOP STANDARD DEFICIENCIES
Section 4
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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.
Written policies and procedures define the required content of the client/patient record. The content includes all items detailed in standard.
• The most common deficiencies are incomplete, missing, initial, and ongoing client/patient assessments and lack of emergency contacts and caregivers
ACHC Standard DRX5-1A:
TOP STANDARD DEFICIENCIES
Section 5
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There is a written plan of care for each client/patient accepted for Pharmacy Services.
The plan of care is developed during the initial evaluation/assessment. Care planning is directed toward driving positive client/patient outcomes.
• The most common deficiencies are incomplete care plans, care plans not being created, and goals not being established
ACHC Standard DRX5-2C:
TOP STANDARD DEFICIENCIES
Section 5
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A Registered Pharmacist reviews all client/patient medications and consults with other healthcare professionals caring for the client/patient, including the physician.
A medication profile is established at the start of therapy. This profile is reviewed prior to dispensing medication and based on therapy protocols, and is updated whenever there are changes in the client's/patient's medication therapy or as designated by the pharmacy’s policies and procedures.
• The most common deficiencies are lack of a medication profile, an incomplete profile or no documentation of review
ACHC Standard DRX5-7A:
TOP STANDARD DEFICIENCIES
Section 5
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The organization reviews and evaluates the effectiveness of the infection control program.
The organization monitors infection statistics of both clients/patients and personnel. Infection control tracking is used to collect and trend data on infections of both personnel and clients/patients.
• The most common deficiency is lack of infection tracking for both patients and personnel or that the logs are not monitored as part of the PI program
ACHC Standard DRX7-1D:
TOP STANDARD DEFICIENCIES
Section 7
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1) Personnel orientation, training and competencies
2) Patient records; Initial assessment, development of the plan of care and updating of the plan of care
3) Quality Outcomes/Performance Improvement
4) Infection Control activities in Section 7
FOCUS YOUR EFFORTS:
TOP DEFICIENCIES OVERVIEW
Sections 4, 5, 6
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RESOURCES
§ Resources available to you for both renewal and initial accreditation:
1) Assigned an ACHC Account Advisor to walk you through both initial and renewal accreditation
2) Customer Central (cc.achc.org)
3) ACHCU.com
• On-demand education
• ACHC Accreditation Guide To Success Pharmacy Workbook (forms and audit tools)
• Complete Pharmacy Performance Improvement Plan
• Listing of upcoming live workshops
• Customized education programs and webinars
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ACTION ITEMS
§ Steps You Can Take Now
1) Go to Customer Central, log in and update your contact and company information
2) Download a current copy of ACHC pharmacy standards
3) Under the resources tab at Customer Central download the “2019 Standards Update Guide”
4) Look to attend an upcoming live workshop or purchase the ACHC Accreditation Guide to Success workbook
5) Contact your ACHC Account Advisor with any questions you may have
6) If renewing your ACHC pharmacy accreditation, submit your application at least six months prior to expiration
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pharmacy
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