As mandatory accreditation and unannounced surveys loom, it is time to make a proactive shift to assure ongoing compliance with accreditation standards, regulatory bodies, and your own written policies and procedures. Achieving accreditation can happen only by consistently improving client care/service and busi-ness stability. This philosophy is not to be tucked away and brought back to life 3 to 6 months prior to the tri-annual accreditation survey.
As a respiratory care practitioner, I have spent years on hospital leadership teams witnessing firsthand the 3- to 6-month accreditation cram prior to the scheduled survey. As a young department head, I wondered why we brought operational and patient care to accreditation standards of excellence and then let it incrementally slide back to the old comfortable style? In light of this, I strongly support unannounced accreditation surveys.
| Warehousing • The warehouse should be clean and organized, have adequate lighting, and should be well ventilated. • The exits shall be marked with lit exit signs to include battery back-up with an emergency light for power failures. • There should be an equipment flow-through pattern in the warehousing area so dirty equipment does not come into contact with clean equipment. • Examples of required signage are: clean equipment, dirty equipment, staging area (segregated from dirty, inoperable, or obsolete equipment), ready for patient use, and fire escape floor plan. • Thorough documentation of equipment cleaning, disinfecting, inspection, and testing to verify operational performance with the date and technician(s) responsible for the evaluation. This should be entered either manually in a cleaning log or by computer documentation. • Equipment preventive maintenance history records should contain any repairs or major servicing that must, at minimum, follow the manufacturer’s guidelines. • All fire extinguishers must be inspected monthly for integrity with date and initials of the person performing the inspection, plus an annual certification by an independent authority. • Material safety data sheets must be up-to-date. • Hazardous chemical storage must be properly designated. • Quarantine area is designated and marked with signage. • Biomedical/repair area is outfitted with proper equipment manufacturer’s service manuals or Internet access, and has tools for oxygen equipment repairs that are marked for oxygen use only. All calibrated instruments for testing of equipment must be up to manufacturer's specifications with certified documentation. • All technicians repairing equipment must have evidence of required specialty training by manufacturers with appropriate certification or documentation. • Providers in states with bedding laws for mattresses and seating surfaces must have the proper disinfecting solutions, tags, and labels with complete documentation per state law. • Companies that provide food pumps must store the enteral solutions in an area where the temperature is monitored by a memory thermometer indicating high/low temperature swings and documented. These solutions must be tracked by lot number, expiration date, and client location in the event of a manufacturer product recall. |
To survive these surveys, companies must implement a system to keep on a continuous track of daily compliance. With the help of a chronological chart, you have a documented compliance confinement map that is organized, directional, and functional. This chart should contain the task heading, compliance process, numerical date, and outcome/goal—remembering that appropriate documentation is necessary to demonstrate compliance.
As you gauge different measures to meet compliance, concentrate on areas that are easy to overlook. I would initially recommend using a calendar to assign a specific day and time of each month for monthly staff meetings, in-service education programs, and quality improvement activities. With an established day and time, staff members become accustomed to the new policy. Decide on the frequency of your staff meetings, which need to be thoroughly documented.
In-house continuing education should include an annual review of clients’ rights and responsibilities, emergency preparedness, safety, infection control, compliance (HIPAA), and ethics-cultural diversity—as well as addressing the required hours as dictated by your policy.
Quality Improvement
The number one pitfall that providers succumb to during the initial survey or tri-annual process is quality improvement (QI). QI is an organized function that improves operational performance. The idea is to take a 360-degree view of the entire system and find ways to maintain continuous compliance.
The QI umbrella encompasses: satisfaction (clients, employees, physicians, referral sources, and contracts); client/employee infections; client/employee incidents; client/employee grievances/complaints; and service/care indicators. A thorough review of all incidents/variances needs to be performed quarterly to detect trends and patterns and decrease occurrences. You must also include an ongoing monitor of at least one important administrative operational aspect of function or service of the organization. These additional activities can be accomplished by including an employee personnel audit (monitor performance appraisals), billing audit, or evaluating the company’s documentation systems.
Wayne M. Link
QI indicators, monitors, or study activities must be assembled using a foundation that is appropriate with methods to collect data. Each activity must include: a description of the indicator(s) and monitor(s)/activities to be conducted; frequency of the activity; who is responsible for conducting the activity; methods of data collection; acceptable limits for findings; who will receive the reports; and plans to reevaluate if findings fail acceptable limits.
From time to time, an activity you have studied may report an outcome that is not within the acceptable range you have set. In this instance an organized plan of correction must be sought. You must have a written policy and procedure to guide the committee through this process, which will identify the problem, seek corrective action, study the activity, and consider assistance that may require governing body action or approval.
I have often scored the QI survey section low because of the lack of employee involvement and understanding of the QI process. Also, remember the involvement of the governing body or organizational leaders is a required standard. This can be accomplished with their periodic attendance at QI meetings, and quarterly and annual QI reports.
| Areas to Monitor • Client services, care management, and reassessment
• Client/patient charts
• Employee personnel files
• Quality improvement outcomes
• Continuing education
• Accreditation agency standard changes
• Emergency preparedness
• Risk management plan
• Utilities management plan
• Contract updates
• Fiscal management
• Corporate compliance
• Warehousing
• Vehicles |
Quarterly client record or chart review must contain an adequate sampling that is representative of each scope of service, including contractual arrangements and both open and closed records. The client/patient chart audit tool will demonstrate several compliance requirements. The quarterly chart audit should be broad enough to satisfy QI and your corporate compliance initiatives.
We have traditionally scrutinized the mechanics of a chart. This includes proper forms, completed documentation, signatures, and current (annual) prescriptions. In addition, we must determine the adequacy of the plan of service or care, appropriateness of continued care, and the achievement of client goals. While you are completing this in-depth chart review, include a billing compliant audit component, which will avoid violations identified by the Department of Health and Human Services and the OIG. Verify that what has been requested or prescribed by a physician has been properly coded and correctly billed.
An annual audit activity that will satisfy the administrative/operational aspect of function or service is the completion of the personnel record audit tool. Numerous compliance measures will be achieved such as annual occupational license recertification, required CEUs, TB testing, performance reviews, competency skills assessments, and valid driver’s licenses.
Remember to include in the annual QI report a summary that describes the activities, findings, and corrective actions that relate to the program services. This should also include QI performance in relationship to the company’s mission philosophy, goals, and objectives as predetermined to assess and evaluate the performance program. There needs to be clear documentation of the involvement of the governing body or organizational leaders that they accept the outcomes or new processes to be further studied in their respective meeting minutes. Information gained from the QI outcomes is used by the organization and must be easily demonstrated for compliance. This is the one instance where the old adage, “If it’s not broke, don’t fix it,” does not apply. By constantly observing and assessing, you can improve on that which does work, solve problems with new insight, and prevent reoccurrences. As stated by a mentor of mine (Sheldon Prial), “You cannot solve a problem with the same level of thinking that created it.”
| Accreditation Awareness? A survey from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Home Health Care Dealer/Provider asked:
Q: Do you know about CMS’ requirement that all HME providers must be accredited to submit payment for Medicare services in 2006 (in selected metropolitan statistical areas)?
• 67.5%: Yes
• 32.5%: No
Q: How are you preparing for accreditation?
• 44.2% have purchased or considered purchasing standards manuals
• 28.8% have begun preparations to become accredited
• 11.5% are working with or plan to hire a consultant
• 11.5% are doing an internal review
• 4% are gathering information
Q: When do you hope to be accredited?
• 10.7% by December 31, 2005.
• 53.6% between January 1 and June 2006.
• 26.8% between July 1 and December 31, 2006
• 5.4% sometime in 2007 or later
• 3.5% Other
Q: Have you decided on an accreditation organization?
• 64.4% are already interested in one or more accreditors
• 23.1% had no accreditor in mind
• 12.5% were not aware of any HME accreditor
Q: How would you prefer to receive information?*
• 85.7% specified an e-mail special list serve
• 58.9% preferred a Web site
• 41.1% preferred a newsletter
• 33.9% preferred journals/magazine articles
* Multiple answers were allowed |
Wayne M. Link is a specialist in HME/DME company accreditation consulting and preparation. He is founder and president of Link Consulting Group Inc, Raleigh, NC, and can be reached via e-mail: wml990@alltel.net.
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