Standard MM.05.01.01 A pharmacist reviews

Can you tell me how other facilities are meeting the following standard:
MM.05.01.01 A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.

We were cited for this in our recent survey at our St. Johnsville Urgent Care site. See below. We do not have a Pyxis in that area at this time.

A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital. EP 1
§482.25(b) - (A-0500) - §482.25(b) Standard: Delivery of Services

In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.
This Standard is NOT MET as evidenced by:

Observed in Individual Tracer at St. Johnsville Urgent Care (7 Timmerman Ave, Saint Johnsville, NY) site for the Hospital deemed service.
On review of the medication administration processes, it was discovered that there is no mechanism in place for a pharmacist to review medication orders prior to administration of medications in the clinic. On further discussion with clinic leadership, the ordering LIP does not control the preparation and administration of the medications which is done by the clinic LPNs. There was also no mechanism in place for retrospective review by pharmacy.
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