1. P HARMACY C OMPLIANCE IN THE ASC Christopher M. Dembny R.Ph. Nov 7, 2013

2. C OMPOUNDING P HARMACIES Necessary? Evil? Necessary Evil?

3. Biography Christopher M. Dembny R.Ph. Licensed pharmacist in Texas for 30 years Consultant pharmacist for surgery centers for 20 years Exclusively practicing in surgery centers and surgical hospitals for 13 years. Currently consulting for > 70 ASC’s ****Feel free to ask questions!

4. Who has regulatory oversight? 1.FDA 1.FDA 2.DEA 2.DEA 3.Texas DPS* 3.Texas DPS* 4.State Board of Pharmacy * 4.State Board of Pharmacy * 5.Texas DSHS 5.Texas DSHS 6.JCAHO (if you pay them) 6.JCAHO (if you pay them) 7.AAAHC (if you pay them) 7.AAAHC (if you pay them) 8.CMS $$$ ** 8.CMS $$$ **

5. What does the TSBP want to see? 1.Annual controlled substance inventory – notarized 2.CII invoices with DEA 222…or CSOS In separate file (signed by RPh and person receiving) 3.Power of attorney to sign DEA 222 4CIII-V invoices (separate) (signed) 5.Controlled substance reproducible audit trail ****

7. What does the TSBP want to see? Controlled substance administration records – Date and time of administration – Patient name – Drug and dose administered – Signature of person administering *** – Waste (if any) and signature of person witnessing waste – Ordering practitioner – Must be maintained separately from chart

8. What does the TSBP want to see? 6.Library is adequate: – A.Pharmacy Rules – B.General Reference Text (Facts & Comp) – C.Drug Interaction text – D.Injectable Products – E.Antidotes and poison control # – F.Weight conversion chart

9. What does the TSBP want to see? 7.Controlled substance documentation 8.Removal of stock log 9.Policies and Procedures(see list in TPR 291.76) 10.Licenses – Pharmacy, DPS, and DEA

10. What does the TSBP want to see? 11.“Adequate security” 12.Transfers to other registrants 13.Loss or theft reports – DEA 106 – Theft or significant loss 14.Save for 2 years 15.Pyxis – Omnicell??????

11. What does the DPS want to see? Licenses Adequate security Reproducible audit trail Secure prescription pads Annual inventories

12. What does DSHS/CMS look for?

13. CMS – CFR 416.48 § 416.48 Condition for coverage—Pharmaceutical services. The ASC must provide drugs and biologicals in a safe and effective manner, in accordance with accepted professional practice, and under the direction of an individual designated responsible for pharmaceutical services. (TPR 291.76) (a) Standard: Administration of drugs. Drugs must be prepared and administered according to established policies and acceptable standards of practice.

14. CMS – CFR 416.48 (1) Adverse reactions must be reported to the physician responsible for the patient and must be documented in the record. (2) Blood and blood products must be administered by only physicians or registered nurses. (3) Orders given orally for drugs and biologicals must be followed by a written order, signed by the prescribing physician. (b) [Reserved]

15. DEA They’ll tell you what they’re looking for. I’ve never seen them visit when there wasn’t already a problem.

16. Questions?????

17. C OMPOUNDING P HARMACIES Necessary? Evil? Necessary Evil?

18. How did we get here? Drug shortages are worse than ever. Cause (my opinion) A.Online ordering – 1.everyone orders the cheapest product B.Lowers price and profit for manufacturer

19. How did we get here? C.Forces some manufacturers out of business D.Others make EXACTLY what they think they will sell. With smaller profit margins, profit disappears if you make too much. E.Now we have fewer manufacturers with less overstock.

20. How did we get here? F.Interruption of supply – 1. Natural disaster – 2.FDA shutdown – 3.Internal problem (strike – retooling) G.If 1 of 10 manufacturers experiences an interruption, no problem H.If 1 of 2 manufacturers experiences an interruption, BIG PROBLEM. SHORTAGES.

21. Problem created A.Shortages of necessary drugs 1.Fentanyl 2.Midazolam 3.Propofol B.Shortages of Crash Cart Drugs 1.Mag Sulfate 2.Sodium Bicarbonate

22. Are Compounding Pharmacies a viable answer? Yes, but choose carefully. Get approval from Med Exec. The cheapest isn’t always the best. The cheapest isn’t always the cheapest -- Ask those who used NECC.

23. Picking a good compounder A.Look for accreditation: – Pharmacy Compounding Accreditation Board (PCAB) – An independent accreditation organization – Appear to be the only one – Very stringent – Can’t ensure everything is perfect

24. Picking a good compounder B.Independent assessment – Consultant pharmacist can be a resource – International Association of Compounding Pharmacists (IACP) http://www.iacprx.org/ http://www.iacprx.org/associations/13421/fil es/CPAQ%20REV%20with%20updated%20me mber%20number%20October%202012.pdf http://www.iacprx.org/associations/13421/fil es/CPAQ%20REV%20with%20updated%20me mber%20number%20October%202012.pdf This is the assessment tool from IACP

25. Picking a good compounder C.Consultant Pharmacist Assessment D.I would use in-state compounders – FDA may prohibit shipping across state lines.

26. Picking a good compounder ************************************ D.Ask for independent analysis – 1.Sterility a. bacterial b. fungal – 2.Quantitative Analysis

28. Contact Information Christopher M. Dembny R.Ph. cdembny@tx.rr.com