Common Problems

With CMS’ accreditation deadline coming up fast (Oct. 1, 2009), the DMEPOS accrediting organizations are conducting numerous unannounced site surveys this summer. One of the most common survey problems for providers is meeting the requirements for personnel, or human resource, files.

Continuing our review, here are some additional items you are required to collect before the surveyor shows up at your doorstep.

• Orientation documentation Accreditors expect to see a copy of the information that providers review with each new hire during their orientation period. These items include reviewing the company’s policies and procedures, mission statement, teaching new employees how to review each piece of required paperwork provided to customers, ensuring that the staff member is competent (see “Competency Evaluations”) to perform tasks/instruct customers, and more. This is best accomplished with a comprehensive orientation checklist that is signed by the staff member. If you implemented an orientation checklist as of a certain date, the surveyor will expect to see that all new hires hired after your form implementation date have a completed orientation checklist in their HR file. You would not be expected to have all staff complete such a checklist after the fact; just ensure that all new staff have done so appropriately.
• Job Descriptions The final Quality Standards require that all staff have job descriptions. Providers must ensure that there is a job description with a job title and relatively complete list of required duties for all staff members, employees or contractors, full- or part-time. The accreditor’s standards will detail any additional items the job description is required to contain, and if it must be signed by the staff member as well. Regardless of when the staff member is hired, your implementation date for this process must be well before your survey, and all staff — old or new — must have received a job description for their current position.
• Annual or Biannual Performance Reviews The accreditors require that you conduct a review of each staff member’s performance in their jobs, either each year or at least every two years (check your accreditor’s individual requirements). This may be a task that you had never documented in the past, but for every staff member who has been employed for at least one year, before an unannounced survey, you must have a completed annual or biannual performance review. Obviously this is not applicable for newly hired employees who have been employed for less than one year.
• Competency Evaluations CMS, and thus its DMEPOS accreditors, require that all staff members who instruct customers on the proper and safe use of the equipment provided must be evaluated to ensure they are competent to perform this instruction independently. Generally, the accreditors require that this evaluation be performed after a newly hired staff member is trained during orientation, and then again annually.

This applies to staff who instruct any customer on equipment (even glucometers and supplies), in person or over the phone, during and after work hours. The accreditor will expect to see completed competency evaluations in the HR file for every staff member, no matter when they were hired, documenting their competency on every item they provide to a customer.

A driver should have a competency completed for every item he delivers and sets up with a customer. This applies to a dispatcher or other staff member who fills in for a driver as well. Additionally, every customer service staff member who provides troubleshooting on the phone, or a staff member who provides assistance after hours, must have completed competency forms in their HR file.

To make sure your HR files are in order, audit them using a checklist that documents every item you need to have in your files, and then audit every file! HR file requirements do not have to be a deficiency on your survey if you take the time to review the requirements, use a good checklist and audit your files to ensure compliance.

Read Part One 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.