Guideline text:
(Rev. 95, Issued: 12-12-13, Effective: 06-07-13, Implementation: 06-07-13)

## [All records must document the following, as appropriate:]

§482.24(c)(4)(viii) -  Final diagnosis with completion of medical records within 30 days following discharge.

## Interpretive Guidelines §482.24(c)(4)(viii)

All medical records must contain a final diagnosis.  All medical records must be complete within 30 days of discharge or outpatient care.

## Survey Procedures §482.24(c)(4)(viii)

Select a sample of patients who have been discharged for more than 30 days.  Request their medical records.  Are those records complete?  Does each record have the patient's final diagnosis?

A-0489

(Rev. 151, Issued: 11-20-15, Effective: 11-20-15, Implementation: 11-20-15)

§482.25 Condition of Participation:  Pharmaceutical Services.

The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision.  The medical staff is responsible for developing policies and procedures that minimize drug errors.  This function may be delegated to the hospital's organized pharmaceutical service.

## Interpretive Guidelines §482.25

A hospital must provide pharmaceutical services that meet the needs of its patients.  The services must include either a pharmacy that is directed by a pharmacist, or, when appropriate, a drug storage area that is competently supervised.  The hospital's medical staff is responsible for developing pharmaceutical policies and procedures that minimize the potential for medication errors, but may delegate this function to the pharmaceutical service.

The manner or degree of noncompliance with the requirements of this Condition and its component standards must be evaluated to determine whether there is substantial noncompliance with the Condition, warranting a Condition-level citation.

A-0490

(Rev. 151, Issued: 11-20-15, Effective: 11-20-15, Implementation: 11-20-15)

Standard-level Tag for §482.25 Condition of Participation:  Pharmaceutical Services.

The hospital must have pharmaceutical services that meet the needs of the patients….

Interpretive Guidelines §482.25

## What is included in pharmaceutical services?

Pharmaceutical services encompass the functions of procuring, storing, compounding, repackaging, and dispensing all medications, biologicals, chemicals and medication-related devices within the hospital.  They also include providing medication-related information to care professionals within the hospital, as well as direct provision of medication-related care.

## Meeting patient needs

Hospitals must provide pharmaceutical services that meet the needs of their patients.  The scope and complexity of pharmaceutical services available in the hospital must be consistent with the volume and types of patients the hospital serves. Except in unusual circumstances, the pharmaceutical service is expected to make available in a timely manner the volume and types of medications typically needed.  These would be those medications typically prescribed by the hospital's practitioners for hospital patients receiving inpatient services, surgical services, diagnostic services involving medications as a component of testing, and outpatient drug therapies administered while the patient is in the hospital.

Not every hospital is expected to offer the same level of pharmaceutical services.  For example:

- It would not be uncommon for a psychiatric hospital to maintain a relatively limited pharmaceutical service, due to minimal need for compounding, and/or dispensing multiple types and forms of medications and biologicals.
- On the other hand, a short-term acute care hospital with a busy oncology outpatient service and other complex medical and surgical departments would be expected to provide a wider range of pharmaceutical services that are ready to be furnished when needed.

## Survey Procedures §482.25

- Ask the hospital for evidence of the scope and complexity of its pharmaceutical services.
- Ask how the hospital has determined that the services meet the needs of its patients.
- Ask unit nursing staff if prescribed medications are routinely available and timely. If there are reports of frequent delays or other problems, probe further with the director of pharmaceutical services.

Structured rule (JSON):
{"intent_tags": ["quality", "compliance", "integrity", "safety"], "logic_config": {"anchor": "discharge", "max_delay_days": 30, "target": "medical record completion"}, "rule_type": "temporal", "scope_tags": ["clinical", "facility", "legal"]}