CAH CoP 2020 Series- Part 2: Pharmacy, Dietary, Maintenance, Board, ED, and Policies

Objectives:-

At the conclusion of part two, participants should be able to:

• Explain the responsibilities of the pharmacists that include developing, supervising, and coordinating activities of the pharmacy.
• Describe the requirements for CAH to monitor and inspect to ensure that outdated drugs are not available for patient use.
• Recall the requirements for  security and storage of medications, medication carts, and anesthesia carts, 
• Discuss the requirement to have a list of do not use abbreviations and a review of sound-alike/look-alike drugs. 

Session Agenda:-

• Physical Plant and Environment
• Disposal of trash
• Storage of drugs
• Physical environment
• Construction and equipment
• Maintenance
• Emergency Procedures-moved to new appendix Z
• Life Safety from Fire
• LSC waivers
• Fire inspections 
• Board section
• Staffing
• Physician responsibilities
• Physician supervision
• Transfer of patient
• Patient admissions
• Patient care policies
• Medical management

Regulations and Interpretive Guidelines for CAHs

• Direct Services
• Services Provided through Agreements or Arrangements
• Drug and biologicals
  • Security of medication, qualifications of pharmacy director, proper environmental conditions, P&P to monitor all carts, compounding, blue box advisories, Drug Quality and Security Act, standards of care, dispensing medications, list of high alert medications, labeling, the definition of a medication error, adverse event, indicator or trigger drugs

Pharmacy

• Inspections/staff interviews
• Dispensing of drugs
• Pharmacist responsibilities
• Staffing in pharmacy
• Pharmacy policies and procedures 
• Medication therapy monitoring
• Pharmacy USP 797 regulations
• Emergency medicine kits
• Drug storage
• Nursing med carts/anesthesia carts
• Outdated drugs
• Survey of pharmacy
• Reporting ADR and medication errors
• Near misses/good catches
• High alert medication
• Definition of medication error required
• Trigger/indicator drugs
• Monitoring medication errors
• Medication alerts
• Standard of care for medications
• Websites and additional resources
• Required pharmacy P&P
• Do not use abbreviations
• Sound-alike/look-alike drugs
• Non-punitive policies

Dietary and Nutrition Services

• Final change
• Dietary policies
• C&P to order diet
• Meeting patient needs, diet order, follow recognized dietary practices
• Dietary compliance
• Qualified dietician
• Dietary support staff
• Assessment of patients and order