HR Information
USP 797
Reporting
Emergency Preparedness
Communications
100

How often does an employee receive performance evaluations?

Twice yearly

100

Completed annually for pharmacists and every 6 months for technicians

What are Media fills, gloved fingertip testing

100

5 days to respond and investigate, 14 day to inform the patient in writing of the results

What is the Medicare complaint response timelines

100

Dumpster in the front parking lot

What is the meeting point for a fire or fire drill

100

How would you provide care to a patient/family with a communication/language barrier?

Translation Line 

200

Training documents are stored in this location

Connecteam 

200

Frequency that surface samples are collected

What is monthly

200

Evidence or suspicion of abuse or neglect

What is to report to the Director of Nursing or the Pharmacy Manager when notified of or suspicion of abuse to a patient

200

Monthly Environmental Audit includes:

What is-

Fire extinguishers in date and in the green

Eye wash exp date checked

No boxes within 18 inches of the ceiling

Emergency route posted

Emergency lighting works


200

What's the first thing you do when an ACHC Surveyor walks in?

Check Identification and escort them to an appropriate workspace

300

The Annual required trainings

What are:

compliance, confidentiality, FWA, cultural diversity, communication barriers, infection control, workplace safety, emergency and disaster planning, OSHA /Hazardous, complaints, patient rights and responsibilities

300

Every 6 month ENV visit includes:

Conduct clean room certification, smoke studies, air velocity, air sampling

300
Method to ensure medications arrive to the patient in a safe and effective form

Shipping temperature verification testing and annual packing observations

300

Safety data sheets are located?

What is in SharePoint - regulatory and compliance, Safety Data sheets

300

Goal for Speed to answer and call abandonment rate

What is less than 30 seconds, 5%.

All calls managed through Orlando, results reported at PI

400

Critical Point, Simplifi, Media Fills

What are compounding training platforms

400

Information required on the compounding record

What is lot number, expiration date, quantity, compounding directions, storage temperature directions for use, copy of the lable

400

 Things that must be reported to ACHC withing 30 days

Change in ownership, change in address, change in CEO, pharmacy license suspension, being fined or penalized by an insurance company or Medicare, any open investigation by a regulatory or federal agency, FDA 483

400

First aid section

What is the important information on the SDS

400

Who might the surveyor interview?

The Surveyor will choose and select staff based on the services provided. In addition, the Surveyor will interview the Administrator and the Clinical Supervisor, as well as a governing body member, if applicable.

500

Compliance Plan review,  

What is required to be reviewed and acknowledged annually for each employee

500

Room Temperature 4 days

Refrigerated 10 days

What is USP 797 sterility guidelines for compounded sterile products.

500

These must be reported to the compliance officer and reviewed at the PI meeting

What is any ethical issues

500

Plan for ongoing patient care if the pharmacy shuts down

What is-

Assess situation

Contact Gregg

If prolonged, transition patients and business to Orlando

Contact BOP regarding inventory

500

List five patient rights.

1. Choose a homecare agency to provide care

2. Be treated with dignity, respect, and consideration

3. Receive all services outlined in the plan of care

4.  Be able to identify visiting personnel members through agency generated photo identification

5.  Voice grievances/complaints regarding treatment or care

Others...

The Right to Obtain Your Medical Records.

The Right to Privacy of Your Medical Records.

The Right to Make a Treatment Choice.

The Right to Informed Consent.

The Right to Refuse Treatment.

The Right to Make Decisions About End-of-Life Care