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Smoothly Navigate the Accreditation Maze

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Specialty Pharmacy Accreditation – Table of Contents

1a. Policy & Procedure Document (ACHC Compliant) Table of Contents:

  • Legal Authority
  • Notification Policy Of Organization Changes
  • Governing Body
  • Governing Body Structure
  • Governing Body Orientation
  • Conflict Of Interest And Disclosure
  • President
  • Absence Of President
  • Mission And Philosophy Statement
  • Strategic Planning
  • Compliance With Federal, State And Local Laws
  • Reporting Of Outcomes
  • Service Description
  • Patient Bill Of Rights And Responsibilities
  • Patient Grievance / Complaint
  • Confidentiality Of Patient Information
  • Patient Abuse Or Neglect
  • Ethical Issues
  • Code Of Ethics
  • Patient Cultural Background And Religious Beliefs
  • Communication Barriers
  • Compliance Program
  • Budget Planning
  • Accounting Activities
  • Financial Record Retention
  • Reimbursement Disclosure
  • Billing Procedures
  • Personnel Management
  • Personnel Recruitment And Interview
  • Job Descriptions
  • Personnel Credentials
  • Employee Requirements
  • Personnel Records
  • Orientation Program
  • Competency Assessment / Supervisor Visits
  • In-Service / Continuing Education
  • Supervision
  • Employee Performance Evaluations
  • Contracted And Purchased Services
  • Patient Record Documentation
  • Patient Record Management
  • Patient Referrals
  • Eligibility Assessment And Guidelines
  • Geographic Area Served
  • Antidiscrimination Compliance
  • Unmet Needs
  • Performance Improvement Plan
  • Infection Control
  • Tuberculosis Infection Control Plan
  • Hepatitis B Infection Control Plan
  • Bloodborne Pathogens Control Plan
  • Infectious Disease Reporting
  • Safety Management
  • Emergency Preparedness Plan
  • Emergency Preparedness Drill
  • Utilities Management
  • Fire Safety
  • Hazardous Waste Management
  • Identification, Handling And Disposal Of Hazardous Materials
  • Hazard Communication Program
  • Incident Reporting
  • Pharmacy Regulations And Qualifications
  • Pharmacy Scope Of Services
  • Pharmacy After Hours Call
  • Pharmacy Supervision
  • Pharmacy Physician License Verification
  • Pharmacy Assessment And Plan Of Care
  • Pharmacy Patient Education
  • Pharmacy Patient Transfer / Discharge
  • Pharmacy Dispensing
  • Labeling Of Medications
  • Pharmacist Education Requirements
  • Adverse Drug Reaction
  • Medication Administration / Treatment
  • Home Medical Equipment
  • Pharmaceutical Recall Or Defect
  • Pharmacy Records
  • Pharmaceutical Compounding
  • Aseptic Room
  • Medication Storage
  • Medication Delivery
  • Pharmacy Reference Library
  • Computer Integrity
  • Drug Inventory Control
  • Patient Information And Drug Security
  • Pharmacy Access
  • Refill Authorization
  • Prescription Delivery By Ups Or Fedex

1b. Policy & Procedure Document (URAC Compliant) Table of Contents:

  • Document Control
  • Policies And Procedures
  • Pharmacy Regulations And Qualifications
  • Placeholder
  • Notification Policy Of Organization Changes
  • Governing Body
  • Conflict Of Interest And Disclosure
  • President
  • Mission And Philosophy Statement
  • Compliance With Federal, State And Local Laws
  • Reporting Of Outcomes
  • Pharmacy Scope Of Services
  • Service Description
  • Patient Bill Of Rights And Responsibilities
  • Placeholder
  • Incident Reporting
  • Patient Grievance / Complaint
  • Confidentiality Of Patient Information
  • Ethical Issues
  • Code Of Ethics
  • Patient Cultural Background And Religious Beliefs
  • Communication Barriers
  • Compliance Program
  • Budget Planning
  • Strategic Planning
  • Accounting Activities
  • Billing Procedures
  • Personnel Records
  • Personnel Credentials
  • Employee Requirements
  • Job Descriptions
  • Personnel Management
  • Employee Performance Evaluations
  • Orientation Program
  • Competency Assessment
  • In-Service / Continuing Education
  • Contracted And Purchased Services
  • Payer Contracts
  • Pharmacy Supervision
  • Pharmacy Clinical Calls And After-Hours Calls
  • Pharmacist Education Requirements
  • Pharmacy Aseptic Room
  • Pharmacy Dispensing Of Medications
  • Pharmacy Reference Library
  • Patient Record Documentation
  • Patient Record Management
  • Call Center / Patient Referrals And Orders
  • Eligibility Assessment And Guidelines
  • Pharmacy Prescription And Assessment
  • Pharmacy Patient Education
  • Pharmacy Counseling Of Patients
  • Medical Supply Products Patient Education
  • Prescription Authentication
  • Pharmacy Dispensing
  • Labeling Of Medications
  • Product Delivery
  • Unmet Needs
  • Patient Discharge/Transfer
  • Quality Improvement Plan
  • Infection Control
  • Tuberculosis Infection Control Plan
  • Hepatitis B Infection Control Plan
  • Infectious Disease Reporting
  • Bloodborne Pathogens Control Plan
  • Needle-Stick Prevention Policy And Procedures
  • Safety Management
  • Patient Home Safety Information
  • Emergency Preparedness Plan
  • Emergency Preparedness Drill
  • Utilities Management
  • Fire Safety
  • Hazardous Waste Management
  • Identification, Handling And Disposal Of Hazardous Materials
  • Hazard Communication Program
  • Pharmaceutical Recall
  • Pharmaceutical Compounding
  • Pharmacy Medication Storage
  • Pharmacy Medication Delivery
  • Enteral Formula
  • Patient Abuse Or Neglect
  • Pharmacy Adverse Drug Reaction
  • Pharmacy Adverse Drug Reaction- Anaphylaxis
  • Pharmacy Medication Errors And Adverse Reactions
  • Materials Management Quality Control Measures
  • Product Tracking
  • Product Recall
  • Product Incidents
  • Product Incident Reporting
  • Home Blood Glucose Meter Procedure
  • Home Healthcare Supplies
  • Pharmacy Records
  • Pharmacy Labeling Of Medications

2. Complete Set of Forms Table of Contents:

(Tailored to your specific company operations)


(Forms correspond to all Policies & Procedures purchased)

  • Governing Body Orientation
  • Against Medical Advice
  • Client/Patient Handouts
  • Client/Patient Bill Of Rights And Responsibilities
  • Supplier Standards
  • How To Make Your Home Safe For Medical Care
  • HIPAA Notice Of Privacy Practices
  • Emergency Planning For The Home Care Client/Patient
  • Advance Directives
  • Making Decisions About Your Health Care
  • Client/Patient Call-Back Form
  • Client/Patient Data Sheet
  • Client/Patient Notes
  • Client/Patient Referral Form
  • Client/Patient Service Agreement
  • Client/Patient Satisfaction Survey
  • Client Visit Report
  • Pulse Oximetry Report
  • Competency Evaluation
  • Concern Form
  • Conflict Of Interest And Disclosure Statement
  • Home Blood Glucose Meter Assessment And Plan Of Service
  • Employee Counseling Form
  • Employee Information Sheet
  • Employee Orientation
  • Employee Satisfaction Survey
  • Employment Conduct Agreement
  • Employment Reference Request
  • Equipment Set Up And Maintenance Log
  • Financial Hardship Information Form
  • Hepatitis-B Immunization Release: Acceptance
  • Hepatitis-B Immunization Release
  • HHS-Tips Hotline
  • HIPAA Notice Of Privacy Practices
  • Protected Health Information Privacy Agreement
  • Incident Report
  • Infection Control Report
  • Inservice Documentation
  • Interview Data Collection
  • Lot Number Tracking Log
  • Medical Questionnaire
  • Performance Appraisal
  • Policy Compliance Statement
  • Referral Satisfaction Survey
  • Safety Evaluation
  • Training Documentation
  • Van Daily Safety Checklist
  • Verbal Order Form
  • Waiver Of Liability
  • Worker’s Compensation Procedures
  • Utilities Management Assessment Log
  • Temperature Log
  • Prescription Solutions Tracking Form

3. Employee Handbook Table of Contents:


(Tailored to your specific company operations)



  • Mission Statement
  • Company History
  • General Employment Practices
  • Employee Conduct
  • Harassment Policy
  • Criminal Background Check
  • Types Of Employees
  • Hours Of Operation
  • Wages
  • Probationary Period
  • Attendance
  • Payday
  • Overtime
  • Workers’ Compensation
  • Dress Code
  • Personal Phone Calls
  • Email And Internet Use Policy
  • Controlled Substance Abuse
  • Grievance Procedure
  • Job Abandonment
  • Discipline / Termination
  • Resignation
  • Driver Qualifications
  • Performance Evaluation
  • Competency Evaluation
  • Vacation
  • Sick Leave
  • Paid Time Off (PTO)
  • Bereavement Pay
  • Holidays
  • Employee Handbook Compliance

4. Job Descriptions Document:

(Tailored to your specific company operations)

5. Company Organizational Chart:

(Tailored to your specific company operations)

6. Quality Improvement Plan Table of Contents:

  • Performance Management Plan
  • Purpose
  • Goal
  • Objectives
  • Accountability
  • QI Committee
  • Data Collection/Evaluation Of Care/Follow-Up Actions
  • Confidentiality
  • Quality Improvement Activities
  • Quality Improvement Meeting Formal
  • QI Summary Report
  • 
Annual Quality Improvement Report

Specialty Pharmacy Accreditation

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