Newsletters

June 2025 - Newsletter

Written by Becky Templeton | Jun 18, 2025 11:40:58 PM

Included in this newsletter

  1. Office Closure- July 4th
  2. Uncredentialed CMS Inspectors Attempting Facility Access
  3. CMS New Program with NCPDP – “Medicare Drug Price Negotiation Program”
  4. Joint Regulatory Statement of The State Medical Board of Ohio, Ohio Board of Pharmacy, and Ohio Board of Nursing Regarding Retail IV Therapy Clinics
  5. Advisory Committee on Immunization Practices (ACIP) Shake-Up
  6. Rite-Aid Closures: Strategic Growth Opportunities
  7. Nationwide Measles Outbreak: A Call to Action for Pharmacies
  8. Departments of Labor, Health and Human Services, and Treasury Announce Move to Strengthen Healthcare Price Transparency
  9. CMS DMEPOS Accreditation Involving the Board of Accreditation/Certification Intl (BOC)
  10. FDA Approves Novavax COVID-19 Shot but with Unusual Restrictions and Evidence-Based Approach
  11. Spotlight on a July Task List Requirement for Quality Improvement
  12. Enforcement
  13. Updated P&P and Forms

Office Holiday Closure

Our office will be closed for Independence Day starting Thursday July 3rd @ 5pm EST and Reopening Monday July 7th @ 8am EST.

Uncredentialed CMS Inspectors Attempting Facility Access

We have received reports of individuals claiming to be CMS inspectors entering pharmacies and DMEPOS facilities without presenting proper credentials.

Please remember that under Medicare Part B, Part C, and Part D regulations, CMS inspectors are required to properly identify themselves upon arrival.  Without valid credentials, they have no authority to conduct inspections or access any information.  You should deny entry and access and not assume the individual is who they claim to be.

Additionally, HIPAA regulations strictly limit access to Protected Health Information (PHI) within your facility.  Only trained employees, authorized business associates, state and federal inspectors with proper identification, and payor auditors are permitted access to PHI.

If someone presents themselves without credentials:

  • Record the date and time of the encounter
  • Note the individual's name and the organization they claim to represent
  • If possible, attempt to take a photo of their ID and face
  • If they refuse and leave, document the encounter in detail using the information you collected.

Please send this documentation to the agency the individual claimed to represent and to HHS/OIG.  The Fraud Hotline poster provides contact information and your Fraud, Waste, and Abuse (FWA) program materials.

Remember, PHI within your facility is a valuable target for fraudsters.  Remain vigilant and protect your patients’ data.

CMS New Program with NCPDP – “Medicare Drug Price Negotiation Program”

Medicare Drug Price Negotiation Program (MDPNP) officially starts Jan. 1, 2026.  CMS is emailing the primary points of contact (or "authorized officials") in the National Council of Prescription Drug Programs dataQ Pharmacy Database ("NCPDP Pharmacy Database") to provide information about enrollment into the Medicare Transaction Facilitator (MTF), which is expected to begin in June 2025.  Read more here

Click Here for Medicare Explanation Video Enroll in the Medicare Transaction Facilitator (MTF)


Joint Regulatory Statement of The State Medical Board of Ohio, Ohio Board of Pharmacy, and Ohio Board of Nursing Regarding Retail IV Therapy Clinics

The Ohio Medical Board has released the following on retail IV therapy clinics.  This statement is the first of its kind, but other states will review and possibly issue their own guidance.  If you have or are thinking about adding IV Therapy to your operation, please review this document.  Click Here

Advisory Committee on Immunization Practices (ACIP) Shake-Up

On June 9th, APhA withheld its endorsement of the ACIP Audit Immunization Schedule. See More…

On June 10th, Health Secretary RFK Jr. abruptly fired the CDC Vaccine Advisory Panel. The Health Secretary took the extraordinary step of firing the expert panel that advises the Centers for Disease Control and Prevention on immunizations, saying the action was needed to restore faith in vaccines. RFK Jr. ousts ACIP group that advises CDC on vaccines | AP News

 “A clean sweep is needed to re-establish public confidence in vaccine science,” Kennedy said in an op-ed published Monday afternoon in the Wall Street Journal.

Rite-Aid Closures:  Strategic Growth Opportunities

With the nationwide closure and sell-off of Rite-Aid pharmacies, many independent and community pharmacies are seeing increased patient inquiries about transferring prescriptions.  This shift presents a strong opportunity to expand your patient base.  Since Rite-Aid did not provide adequate support for Medicare Part C and Part D plans, it's important to be familiar with the best plans available in your area and prioritize accepting patients who are enrolled in them.  These patients often have a better understanding of their benefits and will likely be easier to serve efficiently.  However, it’s also essential not to overlook patients enrolled in less favorable plans.  Take the time to educate them about how their insurance works and let them know that you will reach out during the Medicare Open Enrollment period in October to help them make better-informed decisions that benefit them and your pharmacy.

In addition to gaining new patients, there is also a significant opportunity to strengthen your team.  With so many Rite-Aid locations closing, highly skilled pharmacists and pharmacy technicians may be looking for new positions.  Proactively seek out and interview top talent from these closing stores.  Hiring staff who are already familiar with the patients transferring from Rite-Aid can help provide a smooth transition and foster a sense of continuity and trust.  Overall, this is a key investment in both the growth of your customer base and the strength of your staff to build a more resilient and patient-focused pharmacy.


Nationwide Measles Outbreak:  A Call to Action for Pharmacies

In the wake of the COVID-19 pandemic, public confidence in vaccines and government-led health initiatives has significantly declined.  This growing mistrust has led many parents to forgo routine childhood immunizations.  Consequently, diseases once considered eradicated in the United States, such as measles, which had been eliminated by 2000, are now re-emerging and spreading across communities.

Pharmacies and pharmacists are uniquely positioned to be a trusted voice in restoring confidence in vaccines.  As accessible healthcare providers, pharmacists can play a vital role in educating families about the safety and importance of childhood immunizations.

Community Engagement Opportunity

This public health crisis presents an important opportunity for pharmacies to lead outreach efforts.  By partnering with local organizations such as Parent Teacher Associations (PTAs), YMCAs, YWCAs, and youth centers, pharmacies can:

  • Promote the importance of routine vaccinations
  • Distribute accurate, up-to-date Vaccine Information Statements (VIS)
  • Answer questions and address concerns about vaccine safety
  • Host immunization clinics and educational sessions

Resources for Support

Pharmacies can utilize the Vaccine Information Statements in Chapter 2 of their Immunization Program.  These materials are also readily available through the Immunization Action Coalition.

The PBS film “Protecting Health: Saving Lives” is a powerful resource for broader public education.  This documentary, supported in part by R.J. Hedges & Associates, highlights the importance of vaccines and public health initiatives in safeguarding communities.

By stepping into this leadership role, pharmacies can significantly improve vaccine hesitancy and protect public health, starting with our youngest and most vulnerable.

Departments of Labor, Health and Human Services, and Treasury Announce Move to Strengthen Healthcare Price Transparency

The Labor, Health and Human Services, and Treasury departments took action today to advance President Trump’s directive to ensure Americans have clear, accurate, and actionable information about healthcare prices.

The departments jointly issued a Request for Information (RFI) seeking public input on improving prescription drug price transparency.  The RFI seeks input regarding the prescription drug price disclosure requirements, including information on existing prescription drug file data elements and information on implementation generally, such as the ability of health plans to access necessary data for reporting, as well as state approaches and innovation.  See More…

CMS DMEPOS Accreditation Involving the Board of Accreditation/Certification Intl (BOC)

Some R.J. Hedges & Associates clients may have received an email from BOC with the following statement, “The Centers for Medicare and Medicaid Services (CMS) directed BOC to temporarily stop accepting new DMEPOS applications for reaccreditation and accreditation services from facilities located in California, Florida, New York, and Texas facilities.”

A BOC surveyor was indicted for obstruction, but no criminal action was taken against BOC, however, they are not surveying.  See the Enforcement section below “Miami Inspector Pleads Guilty…”.

R.J. Hedges & Associates’ DMEPOS, Pharmacy, and Compounding programs comply with CMS and Accreditation Commission for Health Care (ACHC) standards.  DMEPOS and Pharmacy accreditation with ACHC require the facility to submit certain policies and procedures for review before the accreditation survey.  We are working toward an exemption from this requirement for our clients.

Compounding accreditation requires no policy and procedure submission, since our compounding program went through a detailed review to receive ACHC compounding certification.

FDA Approves Novavax COVID-19 Shot but with Unusual Restrictions and Evidence-Based Approach

The Food and Drug Administration has approved Novavax’s COVID-19 vaccine, but with unusual restrictions.

Novavax makes the nation’s only traditional protein-based coronavirus vaccine and, until now, the FDA has granted emergency authorization for use in people 12 and older.

On May 15th, the FDA granted the company full approval for its vaccine for use only in adults 65 and older, or those 12 to 64 with at least one health problem that puts them at increased risk from COVID-19.  See More

FDA officials have outlined the rationale behind the shift in U.S. policy on COVID-19 vaccination, which until now has been recommended for all persons aged 6 months and older.  FDA Commissioner Martin A. Makary, MD, MPH, and Center for Biologics Evaluation and Research Director Vinay Prasad, MD, MPH, point to evidence suggesting annual boosters may not be necessary to protect against the most clinically important health outcomes  See More

Spotlight on a July Task List Requirement for Quality Improvement

We are beginning a series of articles based on next month’s task list.  We have had regulations within the DMEPOS Compliance Program for performance management and Compounding Compliance Program for quality assurance, quality control, and performance improvement.  Regulators have a long history of reviewing accreditation organization’s requirements and adding some of those items to inspection checklists.  These programs aim to identify potential problems or work practices that could endanger patients and/or employees and work to prevent and mitigate those events.  Virtually every healthcare specialty has some type of requirement(s) for Quality Improvement.  There are three parts to a quality improvement program:

  • Quality Assurance (QA) is a systematic approach to ensure products and services consistently meet established quality standards and patient expectations. Review current processes. Examples are equipment training, establishing best practices, and the Master Formulation Record (MFR) for compounding operations.
  • Quality Control (QC) is a system of checks and procedures to ensure that a product or service meets a defined set of quality standards or requirements. Reviewing complaints, suggestions for an identified process, or concerns.
  • Performance Improvement (PI) identifies areas where individuals, teams, or organizations can enhance their performance, leading to increased efficiency, productivity, and ultimately, better outcomes.

To fully implement a Quality Improvement program, employees must be trained on your facility's specific protocols, the entire staff should review processes to learn and improve the overall operation and mitigate issues.

Enforcement

Updated Policies & Procedures

Pharmacy:

  • Authorization to Conduct Business
  • Complaints to Covered Entity
  • Consumer Services
  • Disposal
  • Documentation
  • Documentation and Standard Operating Procedures
  • Electronic Prescribing
  • Financial Management and Reports
  • Health Literacy and Culturally Appropriate Communication Requirements
  • Limited English Proficiency
  • Medication Adherence Program Set Up Procedure
  • Medication Expiration Procedures
  • Ownership Disclosure
  • Patient Intake – Pharmaceuticals
  • Reconciliation
  • Scope of Services and Practices

Compounding:

  • Disposal
  • Documentation
  • Documentation and Standard Operating Procedures
  • Patient Intake – Pharmaceuticals
  • Performance Improvement Program

HIPAA:

  • Complaints to Covered Entity
  • Documentation

FWA:

  • Fraud, Waste, and Abuse Prevention

Hazardous Drugs:

  • Disposal
  • Documentation and Standard Operating Procedures

DME:

  • Authorization to Conduct Business
  • Complaints to Covered Entity
  • Consumer Services
  • Documentation
  • Financial Management and Reports
  • General Equipment Cleaning and Storage
  • Health Literacy and Culturally Appropriate Communication Requirements
  • Limited English Proficiency
  • Maintaining Current Accreditation Standards
  • Ownership Disclosure
  • Patient Intake – Durable Medical Equipment
  • Product Education and Training
  • Professional Credentials and Continuing Education
  • Reconciliation
  • Scope of Services and Practices

Human Resources:

  • Background Investigations
  • New Workforce Member Hiring Process
  • Product Education and Training
  • Professional Credentials and Continuing Education

OSHA:

  • Vehicle Safety
  • Immunizations:
  • Documentation

DEA:

  • Background Investigations

Diabetic Shoes:

  • Authorization to Conduct Business
  • Patient Intake – Durable Medical Equipment
  • Product Education and Training
  • Professional Credentials and Continuing Education

Updated Forms

FWA:

  • Fraud, Waste, and Abuse Prevention Training Certificate

Immunizations:

  • Screening Questionnaire for Adult Immunization
  • Standing Orders:
  • DTaP Under 7 Years
  • Hepatitis B to Adults
  • Hepatitis B to Children and Teens
  • IPV to Children and Teens
  • Td/Tdap to Adults
  • Td/Tdap to Children 7 years or Older
  • Tdap to Pregnant Women

Pharmacy:

  • Detailed Product Description:
  • Enteral Nutrition

DME:

  • Detailed Product Descriptions:
  • Ankle-Foot/Knee-Ankle Foot Orthosis
  • Canes and Crutches
  • Commodes
  • External Breast Prostheses
  • External Infusion Pumps
  • External Upper Limb Tremor Stimulator
  • Heating Pads and Heat Lamps

With the release of the 2024 NIOSH list, the RJHedges Completed AoR list has grown to over 265 AoR and many have seen changes. To help our clients remain compliant, we’ve rebuilt the entire AoR Table of Contents to reflect the latest NIOSH structure and drug updates.  Any previously executed AoR’s may need retired and retained for 10 years.  The New version of the AoR’s will need reviewed and signed based on your current Hazardous Drug Inventory.  Pharmacies will need to review their inventory and sign each AoR annually, they are designed with 5 years’ worth of reviews. 

For additional information about Assessments of Risk, please visit our website.  If you would like to order the new Completed Assessments of Risk please go to our order form.