Wayne M. Link

Live by your new standards of excellence. If you have brought your company to a higher level of excellence through your efforts to meet the accreditation quality standards, why not maintain it and practice the new processes daily? Before The Joint Commission implemented the unannounced survey in 2006, many companies would celebrate their accreditation success and then slowly, little by little, slide backward from the new successful processes to the old familiar ways that were out of compliance.

As time passed and the triannual survey neared, panic mode would set in for either the owner or the designated accreditation coordinator. Yes, there were some processes you could quickly bring up to par, several that were extremely difficult to resurrect, and many that were all but impossible to recover before the survey. I first witnessed this phenomenon, which I dubbed the "JCAHO Shuffle," while I was a hospital department head in the late 1960s in Chicago. I asked administration and department heads why there was all the pandemonium every two and half years before The Joint Commission inspectors came in. Why not maintain these standards continuously so they were always in compliance and ready for survey? The answers I received made no sense.

Why not stay in compliance? Because we have a tendency to slide back to familiar thinking—it is easier to do it the old way. This should not be the case. Those days are behind us now with the bold, sensible step toward unannounced surveys as well as the requirements of the CMS Quality Standards Mandate. Your accreditor could show up any time during the triannual period, and I applaud this change.

So what can we do to stay in continuous compliance?

1. Annual performance evaluations are a good start. We put off annual evaluations of our employees for a number of reasons. When it gets down to it, we don't like telling employees about their shortcomings. As owners or supervisors, we should be observing and evaluating our staff's skills daily, then on a monthly basis reviewing with them their job responsibilities along with what needs improving. Identify a plan of correction with the goal to bring the performance of those responsibilities up to a satisfactory level.

With this open dialogue between you and your employees, the annual performance appraisal will be quite easy to complete and reveal no surprises. This open, constructive communication should prove comfortable for both parties involved.

2. Complete competency assessments. Your accreditor will likely request that you complete employee competencies (skills assessments) on a regular basis. The accreditor is not telling you how to complete these; they are simply requiring you to do them. This could be a process of witnessing employees completing their job duties, either in a client's home during equipment setup, in a simulation of a setup done in the warehouse, or at the employee's desk. Document your viewing by writing or using a competency checklist of specific job requirements. You could even be creative by videotaping them performing their job duties, and use the video as a teaching tool to critique the employee and then document the results. All in all, you must document an initial competency during the employee's 90-day probationary period, noting their educational outcomes after orientation and training.

Additionally, whenever you introduce a new job skill or task to an employee, a documented competency must be completed every year or two, depending on the accreditor's requirements. Make a note when employees have demonstrated job competency to their supervisor's satisfaction during a ride-along visit or simulation. The accreditors require this of each employee, not just those who provide direct client contact/care.

3. Continuing education is mandatory by all accreditors with specific educational content and/or hours per year.

Continuing education topics include:

• safety in the workplace and client's home, which governs ergonomics, proper lifting techniques, general home safety, electrical, oxygen, falls assessment, and traveling with oxygen;
• patient rights and responsibilities;
• compliance;
• hazardous materials;
• infection control—to include blood-borne pathogens and TB exposure control, plus universal precautions;
• performance improvement;
• boundary issues;
• ethics; and
• cultural diversities.

4. Continuing educational units (CEUs) are a requirement for employees who have professional credentials and must obtain a specific number of continuing education hours to maintain their licensure. There should be proof of CEUs in either the personnel file or in-service records.

5. Performance improvement plans are ongoing, with continuous input from clients and patients.

COMPLIANCE PROGRAM

The corporate compliance officer should coordinate the billing/coding audit with the QI client chart audit. In this way, the company is not duplicating efforts. The ongoing duties of the compliance officer are checking for changes in Medicare, Medicaid, OIG, HIPAA, accreditation, employee conflict of interest disclosure, and local, state, and federal regulatory updates. All employees should know who the compliance officer is and have a clear understanding of the purpose of the program. They also should feel comfortable divulging any company wrongdoing to the compliance officer.

EMERGENCY PREPAREDNESS

A well-thought-out emergency plan should prepare you for a variety of situations that could impact your business and directly hamper your service. Review different scenarios that include an alternative meeting location in case your business is involved in a disaster. Next, contact your partnering HME company that has agreed to render assistance in such an event, so you can assess its readiness. Review your emergency fan-out phone system and complete an annual mock fire drill with your staff.

There are many advantages to daily compliance besides satisfying your accreditor's standards. Of course, you will enjoy peace of mind knowing that you are always prepared for the unannounced survey, which will happen sometime—by either your accreditor or CMS. Daily compliance is mandatory, not a hit-and-miss style of conducting business. Do yourself, your staff, your clients, your community, and the image of our industry a favor by practicing consistent daily compliance.

Wayne M. Link, RCPT, RCP, is president and founder of the Link Consulting Group Inc, Columbus, NC. He can be reached through his Web site, www.linkconsultinggroup.com, and via e-mail: .