Your survey for ACHC PCAB Accreditation is a collaborative effort between the Surveyor and your organization. Each is responsible for performing certain duties to collectively ensure a successful survey experience.

On the day of your survey, the Surveyor will review numerous documents and other items that support compliance with ACHC PCAB Accreditation Standards and applicable state regulations.

Your organization is responsible for supporting the Surveyor to ensure the process goes smoothly. To assist your Surveyor during your survey for sterile or non-sterile compounding pharmacy services, your organization should do the following:

• Check the Surveyor’s photo ID badge upon arrival.
• Designate a workspace for the Surveyor.
• Appoint a survey liaison (This may be your PI Coordinator or the PIC).
• Provide the Surveyor with the following required documents at the opening conference:
  • Policy and procedure manual and employee handbook
  • Resident and nonresident pharmacy/pharmacist licenses and pharmacy technician licenses/certifications if required by state/company policy
  • Complaint file(s)/log
  • Incident/variance reports
  • Performance improvement (PI) records since your last survey (does not apply to initial surveys)
  • Current organizational chart
  • List of current employees with their job titles and start dates
  • Previous survey/inspection results (NSC, fire department, FDA, etc.), if applicable
  • Binder of safety data sheets (SDS)
  • Records on equipment cleaning, maintenance, and repairs/recalls
• Conduct a brief tour of your organization.
• Ensure your policies and procedures are available for review and/or reference.
• Provide copies of your emergency preparedness plan, PI plan, and any requested administrative documents.
• Provide the patient records and personnel files selected randomly by the Surveyor. A computer must be supplied to the Surveyor to access any electronic records in a “read-only” format.

If you have questions about items requested or deficiencies found, ACHC encourages you to seek clarification from your Surveyor while they are still on site.

During the survey closing conference, your Surveyor will give your pharmacy a preliminary summary of findings. The Surveyor does not make an accreditation determination. After your survey, the Surveyor will submit information collected for processing.

Here to Help

ACHC is more than an accreditor. We are your partner. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242, ext. 458.