Kellie WilsonLong-term and post-acute care providers know one thing to be true: audits can be stressful, time consuming, and costly. For most providers, state audits are an expected “surprise” that can impact workflow and operations for days at a time. They have to be ready at all times during their review window. Failures result in costly fees that, in most cases, could be avoided. For these reasons and more, PharMerica launched its Infection Prevention & Control Program Audit to help providers better prepare and maintain infection prevention (IP) practices within their centers.

“The Infection Prevention & Control Program Audit is designed to alleviate the time requirement, stress, and anxiety that comes with audits,” said Kellie Wilson, vice president of client support services for PharMerica. “We wanted to develop a program that would serve nurses, providers, and ultimately residents by offering a comprehensive review of potential IP shortfalls that could impact their center, cause deficiencies on an audit, and cost them a lot of money and time.”

The initial idea for the program came from a current PharMerica customer. The center was struggling to prioritize its plan to develop an IP program due to limited resources, staffing shortfalls, and a short time frame for preparation. 

“We were already sending our nurse consultants to the centers for a variety of other tasks and skills,” said Wilson. “We simply asked ourselves: could our nurses help our centers better prepare for an audit?”

The answer was a resounding yes. In partnership with Joleann Beene, RN-BC, IP-BC, FACDONA, CDP, CADDCT, PharMerica’s director of nurse consulting services, a team of nurses began building the basic structure of what would come to be the Infection Prevention & Control Program Audit. Beene guided the content of the program based on her four decades of experience working as a clinical leader of multiple long-term care companies, laying out the fundamental pieces of the audit in a way that her team of nurses could replicate.

Joleann Beene, RN“We know centers everywhere are being hit hard by workforce shortages and are turning to agency teams to stay afloat,” Beene said. “This becomes an added challenge for centers, who are relying on teams with no strong affiliation to the facility and no deep knowledge of their specific infection prevention protocols. It becomes an area of vulnerability, and puts extra emphasis on full-time nurses, caregivers, and leadership to become the true stewards of an IP program—which is a lot to ask of a busy team of people.”

The core of the Infection Prevention & Control Program Audit is the mock audit during which nurse consultants move through an audit process in a way that resembles the state’s auditing procedures. Then, like in a real audit, the center is delivered a report with its deficiencies. The critical—and most valuable—difference of PharMerica’s audit is that it comes with the support of nurse consultants, who are able to review the results with the center, help them understand why they would have received a citation on a certain portion, and what they can do about it moving forward. 

“Sometimes, the results are easy fixes, such as teaching staff not to carry linens in a way that they come in contact with their uniforms,” said Beene. “Other times, it’s more complex, like rebuilding some of the systems and protocols that got neglected during the pandemic. But what we know is that infection control remains the top tag cited for facilities, and our audit program can provide the feedback and clarity needed to avoid fines and begin the improvement process.”

Edwin AlvarezIf the results of a center’s state audit are returned with deficiencies, they often result in fines—sometimes to the tune of thousands and thousands of dollars—as well as formal citations of the failures. The mock audit and subsequent conversations about the deficiencies can offer peace of mind and confidence to a workforce in advance of an audit.

“I wanted our center to have an edge on audit season,” said Edwin Alvarez, Country Oaks Care Center’s certified infection preventionist. “We were going through a transition of leadership, and everyone was moving offices. Things were out of place, still in boxes, and we were having difficulty prioritizing. The idea of an audit was well received. My team was comfortable with our nurse consultant, and they knew she would help guide us in the right direction.”

Alvarez noted that after the mock audit was complete, the center received a detailed breakdown of the checklist with the results. 

“Infection prevention and control has become a dramatic responsibility for every facility, and the training of a team can be very difficult,” said Alvarez. “The mock audit gave us a clear range and scope of issues to focus on, and it helped us to determine our priorities moving forward.”

By offering deep expertise amid staffing challenges and focused guidance for improvement, PharMerica’s program can help centers improve their IP practices during their survey window and beyond, benefitting facility, staff, residents, and patients alike. For more information, visit

Mock Survey Program Coming in 2023 

The success of PharMerica’s Infection Prevention & Control Program Audit paved a path for a new service: mock surveys. Similar to the IP audit program, mock surveys will put centers through the survey process, helping to expose vulnerabilities, identify shortfalls, and make a plan for improvement. The mock survey program will launch in 2023. 

To learn more about how PharMerica’s clinical consultants can provide expert advice to help your facility comply with evolving requirements and regulations, visit​