CMS requires that HME companies have completed an application to an accreditation body by January 31, 2009, so providers should be well under way with preparations for a successful survey right now. It is unrealistic to think that accrediting bodies will be surveying the bulk of HME companies in the later part of summer 2009, right before the CMS deadline of September 30, 2009. And it is a sure bet that many providers will be undergoing their survey in the first and second quarters of 2009, shortly after the mandatory application deadline passes.

Getting ready for accreditation is a long-term project, and it is not something that can be completed at the last moment. Providers with multiple locations or more than a handful of employees will be playing catch-up if they have not already begun preparations.

Most accreditation surveyors will include one or two patient home visits, accompanied by your employees, as part of the survey process. It's fine for CMS to have mandatory quality standards that are enforced by the accrediting organizations, but they make sense only if they translate into quality patient care.

Surveyors will want to see how your policies, procedures, and employee training affect the care provided to end users. Like many aspects of accreditation preparation, getting employees ready for a surveyor-accompanied home visit takes time. Understanding what surveyors will be looking for when they assess a home visit will assist you in adequately preparing HME staff members for this aspect of the survey.

A step-by-step approach to the perfect home visit is an easy way to orient staff to the process. You can coach them through the annual supervisory evaluation as part of their training. The skill set of your delivery technicians, respiratory care practitioners, and rehabilitation specialists is integral to the care you offer your patients/clients. Quality care in action will make surveyors and, more importantly, referral sources and patients sit up and take notice.

STEP-BY-STEP

Most surveyors will focus on home visits for recurring rental equipment setups, or follow-up visits for respiratory equipment patients. Typically, they will look at the list of the setups and follow-up visits you have scheduled for the day, and decide which of those they would like to observe.

The first step is to notify patients, clients, and caregivers of the impending visit. With current HIPAA laws, and the HIPAA-compliant business associate agreement included with the accreditation survey agreement, it is not necessary to get a written release from the patient—but it's a nice courtesy to let them know a surveyor will be present during the home visit.

Naturally, you'll want to ensure that the delivery vehicle is well organized and contains all necessary equipment, supplies, and required paperwork. In addition, it is important that the equipment is loaded into the vehicle with respect to segregation of clean and dirty. Following proper infection control procedures is critical to a successful home visit. This means bagging and tagging equipment as "clean and ready" for patient use. It's difficult to actually maintain a "clean" and "dirty" side of the vehicle, so bagging equipment is always preferred.

Your employees should, of course, follow safe driving procedures, including wearing seatbelts and observing posted speed limits and traffic regulations. Upon arrival at the pa­tient's residence, wash your hands with alcohol gel or foam according to the instructions provided on the product you use.

Next, gather all required patient paperwork, equipment, and supplies that will be needed for the visit from the vehicle, and lock the vehicle before the patient visit. Locking the vehicle ensures that any additional patient paperwork, equipment, or supplies that may be on board for other patient visits that day remain under access control.

Generally, a visit for a new equipment setup would require various pieces of paperwork for documentation, such as:

• A new patient packet that contains information you are required to disclose, such as company contact information, hours of operation, a list of patient rights and responsibilities, information about your company's scope of services, a HIPAA privacy notice, a copy of the Medicare Supplier Standards, and information about the company's complaint process. Some accrediting bodies require additional information beyond these items in the introductory information packet you provide to new patients—check your accrediting body standards to make sure the information you provide meets their specific requirements;
• a delivery invoice/proof of delivery document that includes assignment of benefits and release of information statements, along with make, model, and serial number (if applicable) of the products provided;
• equipment education guides or other teaching material for the items provided;
• a basic patient functional assessment, home safety assessment, and plan of care form (required by most accrediting bodies for patients receiving recurring rental items); and
• any additional documentation required for signature for reimbursement purposes, such as an advance beneficiary notice form.

After the employee has introduced herself, she can proceed to the equipment setup process, and instruct the patient in the use of the equipment, following your organization's standard procedures. At a minimum, patient instruction should include information about the proper and safe use of the equipment, patient-required maintenance tasks, and basic trouble-shooting procedures.

The staff member should also instruct the patient to call the HME provider for any equipment problems, rather than to attempt repair of malfunctioning equipment. Keep in mind that products such as oxygen systems and ventilators will require that you provide a back-up system, and the patient or caregiver will also need to be instructed in the use of that equipment.

When the equipment instruction is complete, staff members should confirm that the patient or caregiver understands how to use the equipment, and then document all instruction activities, either on your assessment/plan of care form, or on the delivery ticket itself. After all the required paperwork has been completed, patient or caregiver signatures should be obtained to affirm that delivery and instruction took place, and that the patient was provided with all the required instructional materials, notices, and disclosures.

Some items you provide, such as oxygen delivery systems, positive airway pressure devices to treat sleep apnea, ventilators, infant apnea monitors, and other life-sustaining equipment, will require you to schedule follow-up home visits with the patient at recurring intervals. These follow-ups should take place at the time frames defined within your own policies, but no less frequently than recommended by the manufacturer of the equipment.

There are two main objectives to a patient follow-up visit—the first is to function check all aspects of the equipment, per manufacturer's specifications, to ensure that it is working correctly. The second is to determine if the patient using the equipment is compliant with the physician's prescription and the plan of care that you provided during the initial setup process.

A complete function check of the equipment should be documented on a form that you have designed for that purpose, such as an oxygen concentrator check sheet, apnea monitor follow-up form, or a CPAP/bilevel follow-up form. The form should include fields for documentation of the settings ordered by the physician, as well as a reading of the actual settings the patient was using when the follow-up visit was completed. Any discrepancies between the ordered settings and the settings on the device in use by the patient should be documented and the patient reeducated about the importance of using the device at the prescribed settings. Your follow-up form should also include fields for documenting the complete functionality of the equipment.

Roberta Domos

Your initial plan of care for these types of patients should have included instructions regarding required cleaning of filters or replacement of disposables. Patient care personnel can determine compliance with this aspect of the plan of care by taking an inventory of disposables in the home to make sure they are being used and replaced as instructed, or by asking open-ended questions such as: "How often are you changing your cannula, replacing your aerosol nebulizers, and cleaning the filters on your concentrator?"

Lastly, patient care personnel should document noncompliance with safety precautions associated with the equipment provided, such as improper storage of portable oxygen cylinders, hazardous placement of oxygen concentrators or liquid oxygen vessels in the home, and lack of smoke detectors. Keep in mind that it is not the provider's job to try to force the patient to be compliant with the plan of care, but rather to reinstruct the patient as necessary, and to document that reinstruction. You can expect accreditation surveyors to review previously completed patient documentation, and the documentation you complete during a home visit for equipment setup or follow-up, so it's important that your employees practice good documentation habits now.

When the home visit is complete, the patient care staff member should return to the vehicle and wash their hands with alcohol gel or foam again to comply with expected infection control procedures. If the visit included removing used equipment to be returned to the company, it should be loaded in the vehicle in a manner that segregates it from clean equipment. And of course, it's always a good idea to wear a pair of latex or vinyl gloves when handling equipment removed from the home, but a necessity if the item has visible blood or body fluids on it.

Now it's time to safely drive back to the provider's place of business and follow the company's defined process for turning in the completed patient documentation. With that, your home visit is complete.

DO'S AND DON'TS

• Do ride along with employees after training—prior to survey—to make sure they are following the proper process for home visits.
• Do ensure that patient care staff understands all aspects of the equipment they are setting up or function checking, including proper use, maintenance, trouble-shooting requirements, and safety precautions.
• Do review employees' documentation and paperwork prior to survey to ensure it is being completed correctly.
• Do tell your patient care personnel to relax during a surveyor ride-along, and follow their normal processes, as they have been trained.
• Don't take surveyors on home visits far from your location in an effort to use up time—this annoys the surveyor and forces them to rush through other aspects of the survey (which, in turn, does not benefit your organization).
• Don't forget to have the maintenance record available on request for the equipment in the home during the visit.
• Don't wait until a few weeks before survey to ensure your process meets accrediting body expectations—some aspects take time for your staff to learn and become accustomed to.

The home visit process is an important aspect of your successful accreditation survey, but ultimately it's also a reflection of the professionalism of your company and the quality of care it provides. By following these basic steps, you will be complying with up to a dozen individual accreditation standards depending on the accreditation organization you have chosen—and more importantly, letting your patients, their families, and your referral sources know that quality of care is important to your organization.

Roberta Domos, RRT, is owner and president of Domos HME Consulting Group, a national HME consulting firm based in Redmond, Wash. She can be reached through her Web site: www.hmeconsulting.com.