Common Problems

With numerous providers going through accreditation this summer, many are sharing their experiences and the results of their unannounced accreditation surveys. Occasionally the survey deficiencies I am seeing are unique to the company, but more often they are common among HME providers.

One of the most common problems on survey for providers large and small is meeting the accreditation requirements for personnel, or human resource, files. You must review your accreditor’s individual requirements as some may be unique or program-specific, but overall, each accreditor must ensure that providers meet the HR requirements found in CMS’ Final Quality Standards.

With regard to HR files, many providers going through accreditation for the first time may not have previously collected any documentation from staff other than tax withholding and payroll forms, while others may have very detailed documentation on hand. In either situation, as you implement new forms or processes, be sure to track the implementation date.

In other words, identify the date when you actually implement a process or initiate the use of certain forms or required documentation, because that can be important.

There may be staff members who have been employed for years who would not have every piece of required documentation in their HR file, while there will be newly hired staff members who would be expected to have complete files. More about this as we review.

For starters, each accreditor requires that providers have an individual personnel file for each employed staff member, full or part-time, as well as contractors who are not employees. Some accreditors may additionally require that the provider maintain medical information or I-9 forms separate from the personnel file, no matter what size the company might be. Check your accreditor’s exact standards to ensure you meet their requirements.

The accreditor requires that you keep these HR files “secure,” and some actually require that they be “locked.” Even if you are a very small provider, you will need to demonstrate on your unannounced survey that these files are secure and that they contain all of the accreditor’s applicable required items.

Each accrediting organization provides a detailed list of the items you are required to collect. The types of items they require include:

• Documentation of the date of hire This will identify how long the staff member has been working for you and what documentation is required to be in his/her HR file.
• Background checks/drug testing Medicare does not require background checks or drug testing at this time, but accreditors can require either or both. Many providers also require either or both to ensure that they are hiring appropriate staff, whether or not their accreditor requires it. If your company does require either, or is required to perform either by the accreditor, all appropriate staff members must have the background check and/or drug test.

For example, a provider determines the company is going to require background checks on all drivers as of a certain date. In this case, the company will conduct a background check as each new driver is hired after this date but will perform the checks for all current staff by this date as well. (You would not just check new employees and run the risk of having current drivers on staff with a criminal background.)

Here, the implementation date would again be important because it would provide the date that all prior hires had a background check if one was not performed when they were hired. When the accreditation surveyor reviews the files, he or she would not expect to see the check performed upon hire for existing staff when their hire date precedes the implementation date.

We’ll go over more next time — including orientation documentation, job descriptions, performance reviews and competency evaluations — but to be sure your HR files are survey-ready right now, review your accreditor’s standards closely for additional information about these items and others that will be required.

Read Part Two of “Common Problems.”

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.