Fillable AutomAted medicAtion SyStem Survey Form Board of Pharmacy (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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AutomAted medicAtion SyStem Survey Form Board of Pharmacy (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Board of Pharmacy
124 Halsey Street, 6th Floor, P.O. Box 45013
Newark, New Jersey 07101
AutomAted
medicAtion
SyStem
Survey Form
Pharmacy trade name: ____________________________________________ Date of inspection: __________________________
City where located: _______________________________________________ Bureau assignment: __________________________
I. Type of Automated Medication System
Make: ______________________________________________ Model: ______________________________________________
Date of installation: ________________________ Dept. of Weights and Measures inspection date: _____________________
Operational? Yes No
Comments:
II. Compliance Checking Activity (N.J.A.C. 13:39-10.3)
R.P.I.C. Responsible for Unit: _______________________________________________________________________________
a. 13:39-10.3(a)3 - Pharmacy Testing for Accurate Dispensing:
Last date of testing: __________________________
Results available:
b. 13:39-10.3(b)2 - System Inspected for Expiration Date, Misbranding and Physical Integrity:
Date of last monthly testing: _________________________
Results available:
General comments regarding 13:39-10.3 et seq.:
III. Policies and Procedures (13:39-10.4)
a. Does a written Policies and Procedures S.O.P. exist and is it readily available for review? Yes No
(Table of Contents attached as Exhibit No. __________ )
b. 13:39-10.4(a)6 - Accountability record relative to stocking and removing medications from the automated
medication system.
Is an accountability record which documents all transactions relative to stocking and removing medications
from the automated medication system answered? Yes No
c. 13:39:10.4(b) and (c) - Is an annual review of S.O.P. conducted? Yes No
Date of last review: ______________________________
General comments regarding 13:39-10.4:
IV. Quality Assurance (13:39-10.6)
a. (13:39-10.6(a)2 - Description of procedure to test accuracy of system: (To be conducted at least every six months.)
Date of last testing: __________________________ Results available: ___________________________
b. (13:39-10.6(a)3 - Protocol for Measuring Effectiveness of System: (Briey describe)
c. (13:39-10.6(a)4 - Recurring error reporting: (Briey describe)
d. (13:39-10.6(a)5 - Documentation maintenance regarding the written Quality Assurance Program:
General comments regarding 13:39-10.6:
V. Is any evidence available that “Personnel Training Requirements” are not being satisfactorily met? (13:39-10.4)
Yes No
Comments:
VI. Written Plan for Recovery from a Disaster (13:39-10.7)
a. Does the pharmacy maintain a written plan for recovery from a disaster? Yes No
b. Is a copy of that plan available on site for inspection review? Yes No
c. Does the Recovery Plan include information regarding planning and preparation, response, maintenance, testing of
the plan and notication of appropriate agencies? Yes No
Comments regarding 13:39-10.7:
VII. Written Program for Preventative Maintenance (13:39-10.8)
a. Does the pharmacy maintain a written program for preventative maintenance? Yes No
b. Is a copy of that preventative maintenance written program available for inspection review? Yes No
Comments regarding 13:39-10.8:
Overall miscellaneous remarks/comments:
__________________________________________ _______________________________________
Inspected party representative E.B. inspector
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AutomAted medicAtion SyStem Survey Form Board of Pharmacy (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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