TJC Inspections in the COVID-19 Era

April 2021 - Vol.18 No. 4 - Page #2
Category: Certification Services

Q&A with Robert Campbell, PharmD, BCSCP

Clinical Director, Standards Interpretation Group

Director, Medication Management

The Joint Commission


Pharmacy Purchasing & Products: How have The Joint Commission (TJC) surveys changed in response to COVID-19? Should facilities prepare any differently?

Robert Campbell, PharmD: The primary change is that we are requesting organizations limit the number of people that are face-to-face with the survey teams. During the survey, we require social distancing, and we are increasing our reliance on technology to complete surveys. Whereas the medication management portion of the survey previously would have necessitated an in-person conference with leadership from pharmacy, nursing, and medical staff along with the surveyor, now it is likely to be conducted either through a teleconference call or videoconferencing.

To address this new dynamic, we recommend that the main staff member assigned to the surveyor has access to the other staff members at the facility. The assigned staff member should have a list of contacts by specialty to provide support with questions that arise. They should also have the ability to take thorough, copious notes to share with the rest of the team.

Other than that, the preparation process should remain the same. Looking ahead, TJC is exploring virtual survey options. We are currently working with the Centers for Medicare and Medicaid Services to get approval for additional virtual survey activities. Once that plan is finalized, we will share further details.

PP&P: What changes can hospital pharmacy practitioners expect from TJC in 2021 regarding Medication Management standards?

Campbell: The change likely to have the biggest impact in pharmacy concerns the medication ordering standard for titration orders, MM.04.01.01, which aims to ensure that medication orders are clear and accurate. Effective January 1, 2021, there are additional requirements for titration orders:

“Required elements include the medication name, medication route, initial rate of infusion (dose/unit of time), incremental units to which the rate or dose can be increased or decreased, how often the rate or dose can be changed, the maximum rate or dose of infusion, and the objective clinical measure to be used to guide changes.”1

In addition, as of September 2020, we implemented the concept of block charting as a documentation option for rapid titration in emergent situations:

“A single block charting episode does not extend beyond a four-hour time frame. If a patient’s urgent/emergent situation extends beyond four hours and block charting is continued, a new charting block period must be started.”2

At a minimum, the following elements must be documented for each block charting note:

  • Time of initiation of the charting block
  • Name(s) of the medications administered in the block
  • Starting and ending drip rates during the block
  • Maximum dose given during the block
  • Time of completion for the block
  • Physiologic parameters evaluated to determine the administration of the medications

Finally, TJC also has developed guidance to allow nurses the ability to choose between certain titrated medications in defined scenarios:

“In critical care/procedural settings only, for titrated vasoactive (including inotropes) medications, titrated pain infusions, and titrated sedative agents, the nurse may select between the ordered agents based on the patient’s condition and unique physiological response if all the following criteria are met:

  • An order exists for the medication that is written in accordance with organizational policy
  • It is not prohibited by state law
  • It is allowed by hospital policy or the medication order
  • Competency, as defined by the organization, is complete and documented
  • The nurse must stay within the defined parameters of the order

Situations can occur where similarly acting agents are ordered or medications are ordered for the same indication for the same patient. To ensure compliance with Joint Commission standards, organizations should have a process where all care providers are aware of the intent for multi-modal therapy versus unintended therapeutic duplication.”3

PP&P: What were the top noncompliant TJC standards in 2020?

Campbell: We continue to see facilities struggling with medication management in terms of following the physician’s orders for medication administration, as well as with medication storage requirements. This includes following refrigeration requirements and proper storage of medications outside of the refrigerator. There are also some challenges around medication compounding.

Fortunately, there are clear steps organizations can take to remedy noncompliance in these areas. We strongly recommend conducting ongoing audits to identify areas where medication orders are not being followed appropriately. For example:

  • Are there inconsistencies with following the heparin protocol?
  • Is insulin consistently administered at the right time?
  • Does the PRN indication match the patient’s condition?

Once the organization determines its primary area of focus, we recommend that the protocol be incorporated in the shift-to-shift handoff. For patients on the medication of concern, a quick review of the charting will demonstrate whether it is being administered appropriately. This creates an excellent opportunity for providing feedback and improving processes.

For proper medication storage, organizations should follow the package insert. If the package insert does not address storage conditions, additional evidence-based resources may be used to provide guidance. It is important to note that once medications are removed from refrigeration, the organization is responsible for ensuring that subsequent storage is appropriate and safe.

Specific to medication compounding, we see that many facilities do not review the certification reports for their primary and secondary engineering controls. As a result, they are not taking the necessary actions based on the report results, nor are they documenting appropriate follow-up.

To solve this problem, pharmacy needs to develop a familiarity with the certification report format and understand the contents of the report. Because there is no uniform format for certification reports, pharmacy must work closely with the certifier to understand the report results and then apply those results to documented actions. In addition, pharmacy must develop a partnership with the facilities department, infection control, and leadership, and review the reports together to ensure a comprehensive response to any issues raised in the report.

PP&P: What should pharmacy be concerned with beyond the medication management standards?

Campbell: It is important to note that the Environment of Care (EC) standards also impact pharmacy, as they address the maintenance of patient care equipment. For example, pharmacy should review the process for ensuring that the IV pumps are appropriately programmed for different concentrations of the same medication in order to manage medication shortages. Likewise, the EC standards impact medication storage as well as medication preparation areas on nursing units.

Another key element the EC standards address is leadership. Burnout has been a significant issue among pharmacy staff for quite some time. Leadership must be cognizant of this issue and its impact on staff behavior. Burnout can decrease the commitment to process improvement. Pharmacy leadership must ensure that staff remains comfortable with (and committed to) reporting errors and adverse events.

It is also important to consider the impact that COVID has on worsening the risk of staff burnout. To battle this pandemic, pharmacy staff is being seriously extended. From resource deprivation to extended hours covering for coworkers who are sick or quarantined, pharmacy staff has been asked to increase their efforts while under significant stress. With each subsequent wave of cases, the risk of burnout increases.

PP&P: How is TJC addressing the requirements in USP <800>?

Campbell: Due to the remanding of the 2019 USP <797> revision, USP <800> remains informational only. In response, we allow organizations to either adopt USP <800> for hazardous drug compounding, or they may utilize the 2008 version of USP <797>. We will survey to whichever version they choose to adopt.

We are aware that if you pick USP <800> there will be some contradictions with the 2008 version of USP <797>, and in those cases we encourage organizations to follow USP <800> where those contradictions occur. Conversely, it is completely appropriate to choose to follow the official 2008 version of USP <797>, in which case we will survey to that standard.

PP&P: What resources are available for facilities preparing for TJC inspections?

Campbell: I recommend accredited organizations take advantage of the Connect extranet site; both the self-assessment tool and the compounding checklist are available there. Organizations can also review the frequently asked questions (FAQs) that are available at Finally, if there are additional questions or clarifications needed, we always welcome calls to our Standards Interpretation Group.

PP&P: What is TJC’s current area of focus?

Campbell: Our primary focus right now is to support our health care organizations through the COVID-19 pandemic and make sure they have access to the resources they need. To that end, we are working to consolidate information in a single location on our website and we have expanded applicable FAQs. Simultaneously, we are working with key regulatory bodies to reduce the burden on our accredited organizations during this challenging time.


  1. The Joint Commission. MM.04.01.01, EP 2 Revisions. The Joint Commission. Issued May 20, 2020. Accessed January 19, 2021.
  2. The Joint Commission. Standard FAQs. Issued Sept 4, 2020. Accessed January 19, 2021.
  3. The Joint Commission Clarifies Expectations for Implementing Medication Titration Orders. Jt Comm Perspect. 2020;40(6).

Robert Campbell, PharmD, BCSCP, is the clinical director, Standards Interpretation Group (SIG) for Hospital and Ambulatory Programs at The Joint Commission, providing direction to surveyors and SIG staff to interpret standards. He also serves as the director of medication management for the Joint Commission Enterprise, where he functions as the subject matter expert for medication management related topics and assists with developing, revising, and interpreting standards. Dr. Campbell continues to serve as a TJC surveyor, as well as a reviewer in the Medication Compounding Certification Program.


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