phase 2 as related to the doh survey process
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Phase 2 as Related to the DOH Survey Process Pharmacy Services - PowerPoint PPT Presentation

Phase 2 as Related to the DOH Survey Process Pharmacy Services Richard A. Zelkowitz, RPh, MS, FASCP President, Pharmacon Co. Pharmaceutical Consultants to Health Care Institutions (914) 961-3372 www.PharmaconConsulting.com Phase 2 / DOH


  1. Phase 2 as Related to the DOH Survey Process Pharmacy Services Richard A. Zelkowitz, RPh, MS, FASCP President, Pharmacon Co. Pharmaceutical Consultants to Health Care Institutions (914) 961-3372 www.PharmaconConsulting.com

  2. Phase 2 / DOH Survey Process “Final Rule” Implementation Three Phases…  Phase 1: November 28, 2016  Phase 2: November 28, 2017  Phase 3: November 28, 2019

  3. Phase 2 / DOH Survey Process Phase 1  Drug Regimen Review (DRR)  Reported to attending physician, Medical Director and DNS  Specifies attending physician’s documentation requirement in response to DRR recommendations.  If disagree, why?

  4. Phase 2 / DOH Survey Process  Phase 1, cont.  Policies/Procedures need to address  Time frames for each step of the DRR process  Pharmacist actions when need for urgent action to protect resident

  5. Phase 2 / DOH Survey Process Phase 2 483.45 Pharmacy Services Redefines “Antipsychotic” to “Psychotropic ”  Definition expanded to include  Anti-psychotic  Anti-depressant  Anti-anxiety  Hypnotic ALL REQUIRE GRADUAL DOSE REDUCTION

  6. Phase 2 / DOH Survey Process Phase 2 483.45 Pharmacy Services  Psychotropic PRN Orders limited to 14 days  Unless Physician documents rationale and indicates duration of the PRN order.  This includes meds other than antipsychotics  Anti-anxiety (Ativan, Xanax)  HYPNOTICS ( Ambien, Restoril)  Alternative : MELATONIN

  7. Phase 2 / DOH Survey Process Phase 2 483.45 Pharmacy Services  ANTIPSYCHOTIC PRN Orders limited to 14 days  Cannot be renewed unless the physician evaluates for the appropriateness of that medication. Use of Antipsychotic PRN’s are a Major Survey Risk as an Unnecessary Medication

  8. Phase 2 / DOH Survey Process  Survey Risk Areas  Nursing Station Inspections  Medication Pass  Documentation

  9. Phase 2 / DOH Survey Process  Nursing Station Inspection  Refrigerator  Temperature 36-46 degrees F  Keep Temperature Log  Open Multi-dose Vials & Pens  Must be dated when opened  Discard after expiration date (varies)  Refrigerator should be checked on a daily basis

  10. Phase 2 / DOH Survey Process  Food Storage  Only in Pantry area  None in medication room or REFRIGERATOR  Discharged, Discontinued & Patient Property  Must be segregated  Suppositories  Store as per manufacturer’s guidelines  Room Temperature – In container in medication cabinet  Cool or Cold – In refrigerator

  11. Phase 2 / DOH Survey Process  Medication Cart  Dating of open containers  Xalatan – 6 weeks from opening  Advair – 30 days from opening  Protein Supplements – 30 days  Glucose Control Solutions – 30 days  Expired medications  Old blister cards – PRN meds over 90 days  Stock medications  Nebulizer Solutions – Albuterol & Ipratropium

  12. Phase 2 / DOH Survey Process  Controlled Medications  Control Cabinet  Metal, Double-locked (2 doors), TWO DIFFERENT KEYS, Mounted on the wall  Same regulations apply to refrigerator.  Controlled medications must be removed from medication cart after medication pass  Only controlled medication stored in cabinet – No syringes, No jewelry, No wallets, No hearing aides or batteries. AVIOD CONSTANT OPENING

  13. Phase 2 / DOH Survey Process  Shift Audit  NO BLANK SIGNATURE BOXES  All shifts must reconcile controlled medication count  Reconciliation of controlled medications by 2 nurses  Separate sheet for each Rx

  14. Phase 2 / DOH Survey Process CONTROLLED DRUG RECEIPT LOG Date Resident Drug Rx # Quantity Physician RN Signature Anticipated Quantity Date Received Name and Name & Signature of Date of Returned Returned Room # Strength Receiving Return Nurse

  15. Phase 2 / DOH Survey Process  Release of Control Medication Upon Discharge  Physician must write order stating medication, strength and amount  Must sign waiver for non-childproof container  Release only to responsible party - not ambulance driver

  16. Phase 2 / DOH Survey Process  Emergency Kit  Must be sealed  Preferably with serial number on lock  Expiration date must be clearly discernable  Content list must agree with contents  Should have name and date of sealing Pharmacist  Use Swap System , Do not send individual medications  Controlled Medication Emergency Kit  Stored separately from routine controlled medications  Must be counted each shift by nursing personnel  Par levels MUST be maintained by informing vendor pharmacy each time medication is used

  17. Phase 2 / DOH Survey Process  Medication Pass  Gastrostomy Tube: Infection Control  Dilantin Suspension via G-Tube  Must be separated from feeding – hold feed, wait 60 minutes, flush tube, administer, flush tube, wait 60 minutes, restart feed  Viscous Medication Via G-Tube  Dilute  Watch for residue in cup

  18. Phase 2 / DOH Survey Process  Common Errors  Wrong Number of Tablets Administered  Highlight label and MAR  Check ID  Wait 3 minutes between 2 drops of same ophthalmic medication  Wait 1 minute between each “puff” of inhaler.

  19. Phase 2 / DOH Survey Process  Measurement of Liquids  On flat surface  At eye level  Use proper size water cup (5 oz. vs. 8 oz.)  Charting Omissions & Transcription Errors  Considered medication errors  Check at end of shift  Unavailable Medication / Delay of Delivery  Do not borrow  Do not chart “unavailable”  Contact your pharmacy for availability (via supervisor)  Contact physician for further orders  “Hold until available”

  20. Phase 2 / DOH Survey Process  Crush vs. Liquid  If medication is available in liquid form, even if it is crushable, Physician should order the medication in liquid form  Crush only with MD order  EACH MEDICATION CRUSHED SEPARATELY  Infection Control  HANDWASHING  Gloves should be worn for all Injectable Administration

  21. Phase 2 / DOH Survey Process  Medication Strength & Type  Make sure that actual strength and type of stock medication is the same as the medication order.  Examples:  Calcium with Vitamin D  Fish Oil/Omega 3  Nephrocaps  Vitamin D2 vs. Vitamin D3  Regular vs. Enteric Coated Aspirin

  22. Phase 2 / DOH Survey Process DOCUMENTATION  Medication orders  Strength and quantity of liquids  Route of Administration  Must be consistent – PO or G/T  Medication Indication for Use  Antipsychotic – Must have Psychotic Indication  (NOT DEMENTIA OR AGITATION) Schizophrenia, Bipolar  NON-PHARMACOLOGIC INTERVENTIONS MUST BE  TRIED FIRST ( EVEN AFTER FAILED GDR )

  23. Phase 2 / DOH Survey Process  PRN Use – Reason and Follow-Up  Anti-anxiety Medication  Must document failure of behavioral interventions  Caution with use, MAY BE CONSIDERED CHEMICAL RESTRAINTS.  14 day limit  Analgesics  Acetaminophen < 3 gm/day  Interactions  Synthroid & Calcium  Levaquin & Iron  WARFARIN

  24. Phase 2 / DOH Survey Process  Medication Refusal  Proper documentation by nursing and physician  Proper destruction of refused dose  Crush and destroy in water  Prevnar 13 vs. Pneumovax 23  Check CMS site if previously administered  Prevnar first  One year (and one day) in between

  25. Phase 2 / DOH Survey Process  TREATMENT OF PAIN  Frequent use of PRN Medications  Order as routine  Use of 2 or more analgesics  Document need and efficacy  Use pain scale  Pre-treatment analgesia  Must be timed properly

  26. Phase 2 / DOH Survey Process  MONITORING  Warfarin  INR: ordered, picked up, obtained, MD notified  Increased monitoring with antibiotics  Administer at 9 PM (allow time to adjust re: lab work)  Anti-Diabetic  Fingerstick – NO GAPS, Follow sliding scale  Is Sliding Scale needed??  Anti-Hypertensive  BP Parameters – NO GAPS  MINIMIZE USE OF HOLD PARAMETERS

  27. Phase 2 / DOH Survey Process  Laboratory Tests  Results should be filed in a timely manner  Results should be signed and noted by physician  Psychiatric Consults  Should be done at least every 3 to 6 months  Attempt at dose reduction or reason why not  “I have personally assessed this resident to determine the need for a GDR and because he/she has a diagnosed enduring condition of _______, a GDR is clinically contra- indicated at this time.”  Benefit vs. Risk

  28. Phase 2 / DOH Survey Process  New Concerns  Interim MRR for new admission, significant change and short term residents  Must have system in place  May be done off-site

  29. Phase 2 / DOH Survey Process Questions? rzelkowitz@pharmaconconsulting.com

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