USP-NF Chapter 797

We have a Pharmacy area that is not compliant with the Chapter 797 ruling in the mixing room that will be renovated in the next year but not before our survey, is this something that would fall under the EOC Guidelines?  

First of all, this is not a Life Safety Code® issue or deficiency. Therefore, it is not necessary to include any corrective actions for the pharmacy mixing room on an SOC/PFI. However, the TJC surveyors might inquire about your plans and timeframe for performing your mixing room renovations as this is a part of TJC compliance for providing a safe environment for patients & staff.  Please note, some states require compliance with USP 797. The organization should check with their State Board of Pharmacy for their specific requirements for the design, construction, operation, inspection and testing of pharmacy sterile compounding areas.