ASC Medication Survey Readiness Checklist

By Jonathan Lim, PharmD

The ten-minute standard: when a surveyor asks, your team should be able to produce each of these in under ten minutes. Walk your medication room with this list and mark what you can pull today. Your consultant pharmacist can help close whatever is left.

1. Controlled substance log for any date range. Every entry witnessed and signed. DEA 21 CFR 1304 recordkeeping.
2. Count and reconciliation records. Every discrepancy documented and resolved, not just noted. TSBP 291.76 for Texas facilities.
3. Temperature logs for every storage unit. Refrigerators, freezers, and the room itself, with a corrective action on every excursion.
4. Crash cart and emergency box check history. Every seal accounted for, every check dated and initialed.
5. Drug destruction records. Witnesses named and method documented for every destruction event.
6. Your DEA biennial inventory. Dated, signed, and on hand, not "somewhere in the binder."
7. Staff medication education records, per person. Who was trained, on what, and when.
8. Medication-related incident reports. Each one with its follow-up documented, so the story has an ending.
9. Your consultant pharmacist's visit reports and findings. Surveyors read these to see whether findings get acted on. AAAHC Chapter 8.
10. Expired-drug sweep evidence. Proof the sweeps happen, not just a policy saying they should.
11. Your PMP reporting confirmations. Submission receipts, not just the intent to submit.
12. Policies with current staff attestations. The policy binder plus signatures showing your team has read this year's versions.

If any of these takes longer than ten minutes on paper, that's the gap surveyors find. TOM MMS generates every one on demand.

Want to see it live? Book a demo or write to jon@tompharmacy.com. Print this page and keep it in your medication room.