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This is an excerpt from a member-only article. To read the article in its entirety, please login or subscribe.

Air pressures, cleaning, and maintenance critical to sterile compounding areas

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March 1, 2019

Work with your pharmacy and infection control teams to ensure your facility’s sterile compounding area maintains the proper air pressures in the correct areas, ceilings are air-tight, and issues with cleaning, maintenance, and supply storage are addressed.

Also ensure areas are vented correctly and labeled outside so that anyone working around the vent is aware of the hazard.

Problems found connected to sterile compounding areas can — and have — lead to preliminary denial of accreditation and condition-level deficiencies, warns Jennifer Cowel, president of Patton Healthcare Consulting and a former director of service operations for The Joint Commission (TJC).

Pharmacy surveyors and many physician and nurse surveyors with The Joint Commission and CMS now have extensive training in USP <797>, the U.S. Pharmacopeia’s standard on sterile compounding, which in 2015 was adopted into Medicare’s State Operations Manual (SOMA) of interpretive guidelines on implementing the Conditions of Participation (CoP).

Work with your pharmacy and infection control teams to ensure your facility’s sterile compounding area maintains the proper air pressures in the correct areas, ceilings are air-tight, and issues with cleaning, maintenance, and supply storage are addressed.



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