Pharmaceutical Services Conditions of Participation

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Start Time:12:00 AM
End Time:12:00 AM
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Provided by MHA Health Institute.
Health Institute

Date & Time

Wednesday, April 22
10 a.m. to Noon

Register on or before Sunday, April 19, to ensure delivery of instructional materials.

Each webinar registration fee is for one connection. Each additional connection will be charged a separate registration fee. Get more value by inviting colleagues to join you on a single connection.

Can’t attend the webinar? Would you like to share the webinar with your department or team? No worries! Register now, and you will have access to the webinar recording for four weeks after the presentation.

This webinar is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from the MHA Management Services Corporation. This webinar also is eligible for use of the MHA Health Institute coupon. Note: Coupons were mailed to MHA-member hospital CEOs in December 2019.


This program is intended for hospitals accredited by Joint Commission of Healthcare Organizations (JCAHO) and Det Norske Veritas (DNV), and staff including CEOs, CNOs, nurses, nursing directors, pharmacists, JCAHO/DNV liaison staff, quality improvement staff and others responsible for ensuring compliance with the regulations.

The following program content was provided by the speaker.


The provision of pharmaceutical services in a hospital is under increased scrutiny. Recent charges from CMS have heightened the amount of time that surveyors spend reviewing compliance with the pharmaceutical condition of participation. Every hospital and pharmacist needs to understand the CMS requirements for standing orders, beyond use dates, preparation of compounded sterile drugs, secure drug storage requirements and medication self-administration requirements.


At the conclusion of this session, participants will be able to:

  • Describe requirements for the provision of pharmaceutical services.
  • Describe requirements for drug removal from a pharmacy when no pharmacist is present.
  • Discuss beyond use date requirements.
  • Explain the documentation necessary for a patient to self-administer hospital-issued medication from home.


Nancy Ruzicka is a consultant on state and federal rules, regulations and interpretative guidelines. She previously worked as director of integrity and compliance and privacy official at MercyOne Des Moines and director of regulatory compliance at UnityPoint Health-Des Moines. She also has more than 20 years of experience with the Iowa Department of Inspections and Appeals. Ruzicka holds master’s degrees in health law and business administration and a bachelor’s degree in pharmacy, all from Drake University. She is certified in health care compliance and maintains her Iowa pharmacy license.