The majority of HME companies that began the accreditation
process started in 2008, and now those suppliers will be due for
accreditation renewal in 2011 — which is just over one month
away.
Here are the main questions you need to review prior to your
renewal:
What are your requirements (daily, monthly and quarterly), and
are you staying on top of them?
Daily: Your daily requirements include all
compliance items, such as the paperwork you provide to your
patients. Are you handing out the new 30 Supplier Standards?
Make sure your staff is collecting the appropriate documentation
that will be needed for audit purposes, that you are conducting
customer satisfaction surveys appropriately, maintaining required
logs and that you are providing the correct phone numbers for
customers to file complaints.
Monthly: While you must keep up with daily
activities, also make certain you are meeting human resource
requirements. Review your accreditor's requirements as some are
program-specific, but overall, each accreditor must ensure that
suppliers meet the HR requirements found in the CMS Final Quality
Standards.
These requirements include complete orientation and competency
checks for new employees, monthly educational programs for all
staff as well as annual performance reviews. Each accreditor
provides a detailed list of items the supplier is required to
collect, including an individual personnel file for each employed
staff member, full- or part-time, as well as contractors who are
not employees.
Another item to remember here: Medicare does not require either
background checks or drug testing at this time, but several
accreditors require either or both. If your company requires either
or both, be certain that your HR files are complete with this
documentation.
Make sure to check your accreditor's specific requirements, use
a checklist that documents every item you need to have in your HR
files, and then audit every file!
Quarterly: The most important quarterly
requirements to maintain are your quarterly Performance Management
Activities. The CMS Final Quality Standards require that suppliers
"implement a performance management plan that measures outcomes of
customer service, billing practices and adverse events and, at a
minimum, measure:
Beneficiary satisfaction and complaints;
Timeliness of response to questions, problems and concerns;
Impact of business practices on adequacy of beneficiary access
to items, services, information;
Frequency of billing/coding errors; and
Adverse events to beneficiaries due to inadequate services) or
malfunctioning equipment and/or item(s) (e.g. injuries, accidents,
signs and symptoms of infection, hospitalization)."
Are you reviewing your customer satisfaction survey data and
making changes accordingly? Have you summarized the logs you
maintain, such as your billing and coding error log, your
after-hours call log and your adverse events log? Do you have the
data totaled by quarter for each quarter since you were
accredited?
What has changed since you were accredited?
Did you hire new staff? Have you added new products? Did you
open any new locations? All of these issues present accreditation
concerns and would require additional follow-through on your part
to ensure that you have all of the documentation needed for your
accreditation renewal survey.
How early must you begin your renewal in order to meet CMS
deadlines?
Generally, your accreditation renewal timeline should start at
least four to six months in advance of your renewal date. Notify
your accreditor that you are ready for your unannounced survey at
least three months before your accreditation expiration date. That
will allow a 30- to 60-day window for your unannounced survey to
occur, and then give you at least 30 days to complete any follow-up
activities that may need to be conducted if deficiencies are found
on the survey.
Given that renewals are coming up for so many providers, make
sure you are on the right track and on time!
Read more Accreditation Now
columns.
Mary Ellen Conway, RN, BSN, is president of Capital
Healthcare Group, LLC, Bethesda, Md., which provides health
care management expertise in accreditation preparation and survey
follow-up, operations assistance, design of quality improvement
programs and outcome measures. She can be contacted by phone at
301/896-0193 or through www.capitalhealthcaregroup.com.
