Pharmacies Show Strong Compliance Gains
By: Caroline Girardeau, PharmD, MBA, PMP, BCPS, Program Director
Caroline Girardeau brings more than 30 years of pharmacy experience to her position as Program Director for ACHC Pharmacy and PCAB (Compounding Pharmacy) Accreditation. She combines clinical expertise with a passion for education, quality, and performance improvement to help pharmacies strengthen their practices and deliver safe, patient-centered care.
Posted: December 22, 2025
ACHC Pharmacy Accreditation spans a wide range of services. In 2025, pharmacies accredited for ambulatory infusion centers/suites, community retail, mail order, and specialty pharmacy services demonstrated notable compliance improvement from three years ago, when this cohort was last surveyed.
In the latest Quality Review edition of Surveyor, six standards were cited for noncompliance on 15% of surveys—down significantly from 2022, when 13 deficiencies were identified on 20% of surveys. The three most frequently cited standards, DRX5-2B, DRX5-2C, and DRX7-9A, were still the most challenging in 2025 but the remaining 10 standards from 2022 all fell below this year’s 15% threshold, signaling continued progress.
Infusion pharmacy findings
Infusion pharmacies in this same cohort were surveyed for the first time under ACHC Standards that were revised to incorporate updated USP requirements. Overall, eight standards were cited frequently for deficiencies. Survey findings indicate that many organizations had not yet aligned their processes with current USP <797> requirements for sterile preparations.
New this year
Continuous improvement is woven into all we do at ACHC, including the annual Quality Review edition of Surveyor. In our recent issue, “tips for compliance” under each standard profile are enhanced to address varying levels of accreditation knowledge and experience across your agency. Explore our new Accreditation Nerd categories to see which is best for you.
—
Discover more articles about ACHC Pharmacy Accreditation.