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Based on interview and record review, the facility failed to ensure adequate monitoring and evaluation of its pharmacy contract services. The pharmacy consultants did not adhere to provisions set forth in the facility's pharmacy contract regarding availability of services 24 hours per day. This resulted in non-compliance of pharmacy related regulations as well as facility policy. (Refer to C 276, Finding 1)

Findings:

Records of eight patients were reviewed to determine the response time of the Consultant Pharmacist for the first dose medication regimen review. The first dose medication review response time for seven of the eight patients ranged from three to more than five days, and was greater than 12 hours for the other patient.

The facility's policy, "Medication Management: Administration," approved on 2/2013, was reviewed. It read as follows: Medication may only be administered based on an order from a Provider and a first dose review by the Pharmacist via fax to the "Pharmacy Consultant". The Pharmacist's first dose review may not occur in the event of an emergency or when there was a Provider present who is in direct control of the medications being administered.

The "Pharmacy Services Agreement" was reviewed. It read as follows under "Obligations of the Pharmacy", section B, "Pharmacy shall have a licensed pharmacist available 24 hours each day, seven days per week to respond to Customer's requests for pharmacist consultation."

During an interview on 8/22/13 at 11:20 am, the Quality Nurse W stated they currently had no way to evaluate the performance of the pharmacy contract services. She confirmed that it was necessary to evaluate the services to determine if the pharmacy performed in an acceptable manner.