TJC transformed its accreditation and certification process through introducing Accreditation 360 on June 30, 2025. This comprehensive evaluation dramatically streamlines and simplifies processes, such as reducing hospital accreditation program (HAP) requirements from 1,551 to 774, in hopes of providing better support to healthcare entities and offering a mechanism to efficiently share best practices throughout the healthcare ecosystem. A TJC Survey Process Guide (SPG) was created as a unified, streamlined resource to organize standards, regulatory requirements, and survey procedures into a single document. The SPG replaces the Survey Activity Guide and is effective as of January 1, 2026.
Ten medication storage compliance observations from TJC
The following items are the top medication management quality themes from 2025 surveys conducted before the TJC ASHP Midyear presentation on December 8, 2025. The 2025 medication management standard (MM) and the 2026 Accreditation 360 MM standard (A360) are both provided for reference and crosswalks, along with the elements of performance (EP), as pharmacy practices continually prepare for TJC inspection readiness.
1. Medication administration per order (MM.06.01.01 EP 3; A360 MM.16.01.01 EP 2)
Are medications being administered according to the most recent provider orders? Non-compliant findings included administering medications for pain scores outside of the ordered range, titrating infusions incorrectly, and failing to document patient preferences when deviating from the most recent medication order signed by the provider. Ensure that staff notify providers when orders are not followed and use required assessments prior to medication administration and titration.
2. Clean medication prep space and technique (MM.05.01.07 EP 2; A360 MM.15.01.01 EP 2)
Are team members following hand hygiene SOP every time they enter classified areas? Non-compliant findings cited included not using a nail pick under running water, not washing up to the elbows, and failing to use lint-free towels to dry the hands and arms.
In addition, garbing misadventures included wearing jewelry (when prohibited by the organization’s SOP), improper donning of PPE, and failing to cover hair or facial hair. Other non-compliant findings included inconsistent cleaning and disinfection practices of the Primary Engineering Controls (PECs) and Secondary Engineering Controls (SECs). Ensure team members follow your SOPs and that your SOPs reflect current and expected practices.
3. Pharmacy compounding environment (MM.05.01.07 EP 4; A360 MM.15.01.01 EP 4)
When was the last time you did a facility rounds to ensure that peeling paint, floor seal cracks, and unsealed ceiling tiles were addressed? These observations were noted among other structural issues in the compounding classified areas during live surveys. In addition to personnel and technique non-compliant items, there also were observations regarding the compounding environment itself. For example, missing or unfollowed cleaning protocols resulting in residue, dust, and debris on compounding equipment and work surfaces or expired cleaning products were found during surveys.
4. Clarify medication order concerns (MM.05.01.01 EP 11; A360 MM.11.01.01 EP 1)
Despite having policies for pharmacist review and clarification, there were observations of active medication orders with unresolved duplications or ambiguities. Ambiguities included cases in which two or more PRN medications were ordered for the same pain score or medication orders lacking dosing parameters, titration instructions, or specific clinical endpoints. Ensure incomplete or unclear medication orders are clarified prior to medication administration.
5. Stored medications and label requirements (MM.03.01.01 EP 7; A360 MM.13.01.01 EP 4)
Is your healthcare organization consistently applying updated expiration dates or beyond use dates (BUD) after opening and removing the protective overwrap? TJC noted these issues in various departments, including emergency departments, pharmacies, operating rooms, and outpatient clinics. For items labeled with a revised expiration date or BUD, the committee’s observations highlighted inconsistency in how dates were assigned, incorrect durations, or an omission of date when expected.
6. Removal of expired and damaged medications (MM.03.01.01 EP 8; A360 MM.13.01.01 EP 4)
What are your organization’s policies for reviewing active inventory, identifying expired items (including medications), and sequestering them from non-expired inventory? In addition to expired medications, including IV fluids, injectable drugs, and vaccines being found in the clinical areas, TJC surveys noted damaged and potentially contaminated medications co-mingled with patient use medications. Ensure your team follows your organization’s medication storage policies and routinely audits all areas where medications are stored and administered.
7. Storage per package insert (MM.03.01.01 EP 2; A360 MM.11.01.01 EP 1)
When your organization receives drug inventory from a new manufacturer or 503B supplier, who reviews the storage instructions and ensures storage instructions are followed? This includes improper dating after drug inventory is moved from the freezer to a refrigerator or from a refrigerator to ambient room temperature. Medication storage policies should address monitoring of all areas where drug inventory is stored, including clinical areas that may be closed on weekends or holiday times.
8. Completed medication order policy (MM.04.01.01 EP 2; A360 MM.14.01.01 EP 3)
While the adoption of electronic prescribing helps facilitate and streamline the medication ordering process, TJC noted a significant number of instances where elements of the medication order were missing. This includes dose, route, frequency, or specific clinical parameters for titrating or ending medication adjustments. A completed medication order provides defined parameters, and uses of “fever,” “comfort,” or “less pain” cause ambiguity and inconsistency in interpretation and administration. Ensure that medication orders are written so that each person follows the order the exact same way every time.
9. Competencies for pharmacy compounding (MM.05.01.07 EP 3; A360 MM.15.01.01 EP3)
Does your organization have a policy and a competency assessment for immediate use compounding? This includes any procedural or patient care areas where staff perform immediate use compounding. TJC found cases of missing or overdue competency elements, such as media fill testing and annual training requirements. Tracking of education and competency can be labor intensive, so solutions like Simplifi 797 help with oversight from assignment to completion, including automated notifications when completions are delayed or incomplete.
10. Medication dispensing prior to pharmacy review (MM.05.01.01 EP 1; A360 MM.11.01.01 EP 1)
Are your pharmacists involved in reviewing all medication orders before they are dispensed and administered to patients? TJC observed situations where therapeutic duplication occurred and without clear guidance on how each medication should be administered appropriately. Your organization should have a policy that describes pharmacy processes for minimizing therapeutic duplication and clarifies unclear or incomplete medication orders prior to patient administration.
Solutions to support medication storage compliance
With technologies like Simplifi+ MedStorage, you can streamline medication storage, stay compliant for the Joint Commission survey, and ensure patient and staff safety. From task management to environmental monitoring, the Simplifi+ Suite automates critical processes, reduces regulatory risks, and supports audit readiness.