Inpatient PharmacyMedicare Issues

Qualifi

ed

Com

pete

nt

Pharm

acy

Sta

ff

Hospitals will ensure

qualified & competent staff.

Staff Defined: Paid employees, leased/contracted persons,

students & volunteers.Qualified Defined: Person

who has met the requirements for a specific

position by education,

training, experience,

licensure, or certification.

Evi

dence

d B

y

Process of on-going skill/competency assessment. Opportunities for education

and development.Periodic performance review.

Provision of specialized

training, education, and skill

development for specific

tasks or positions.Orientation on general and

department measures.

Cita

tions

Reflect

Failure to establish staff

competency standards.

Failure to ensure that licensed,

certified or registered staff

practice only within their

scope practice.

Failure by a hospital to provide

and document staff

competency for duties.

Pharm

acy

: Pr

epare

, D

ispense

, A

dm

inis

trati

on Requirement that

hospitals assure that

patient pharmaceutical

needs are met in a planned and organized

manner.

Hospitals comply with

the Board of Pharmacy

regulations for a hospital

pharmacy license.

Cit

ati

ons

Reflect

Failure to have an organized, systematic

pharmacy service. Failure to have clear

orders for medications.

Failure to monitor medication effectiveness

or therapeutic levels.Failure to review and

assure pharmacy approval of medication

protocols.

Failure to authenticate

medication orders according to policy.

Failure to monitor for,

remove outdated medications.Failure to label

medications in syringes.

Failure to keep medications secure according to hospital

policy.