Are You Accreditation Ready Every Day?

Think back to the first time you were accredited, which was probably way back in the summer of 2009. You were then re-accredited in 2012. Was your re-accreditation more challenging than the initial survey? Most likely, it was more difficult the second time. That’s because you didn’t have an accreditation history of compliance before your first accreditation. By the time the second accreditation came along, there was a three-year history of accreditation and there should have been processes in place for three years to ensure that the HR files were up-to-date, the patient records were complete, the quality improvement data was being collected and measured and so on. Now it’s 2015 and here you go again. Didn’t you tell yourself that you wouldn’t fall behind this time? Well, if you have, here a few tips for pulling it all together before your 2015 survey.

1. Start Early

Maybe it’s too late for you to start early, but get on the ball quickly. Your accreditation expires on the end date and your accreditor has to file your status with CMS. Your survey has to be unannounced, thus you should be ready for an unannounced survey at least 6-8 weeks (or more) before your expiration date, to allow for adequate response and correction.

2. Read Your Last Survey Report

Make sure ALL of those deficiencies have been corrected and that you are compliant with every issue you had cited before.

3. Clean and Organize Your Delivery Vehicles

Make sure all of your delivery vehicles are clean, both inside and out, and that they are in good order. Make sure your drivers are segregating clean and dirty items. Ensure that tools are secure and clean, alcohol hand cleaner is accessible and that all equipment is secured with straps. If you transport oxygen tanks, be sure they are secure in a cage that is mounted to the floor with netting overtop.

4. Check Your HR Files

Your surveyor may ask for a census or an organizational chart to select files for review, or he/she might give you the option of pulling files yourself. They will usually ask to see the file of a newly hired staff member, so be sure that your HR files are complete for all new hires.

5. Review Your On-Call Log

Surveyors often ask to see your on-call or afterhours log for two reasons.

• To make sure you have one (it’s a Medicare requirement)
   
• To look for troubles or problems, especially repeat problems
   

Read your log as a surveyor would. Ensure that everything documented falls within the accreditor’s standards.

6. Patient Records

Make sure that your records are easily accessible and complete with the necessary patient – acknowledged forms. Check your accreditor’s standards to find a list of the items you must provide and have on file.

7. Quality/Performance Improvement Activities

Summarize all of your quality improvement activities. This is one area where suppliers do not keep up with the data quarterly. This is not meant to be a comprehensive list of preparation activities, just a quick reminder of some of the big items you need to focus on. You really should build your accreditor’s requirements into your daily practices. If you need help, get it, and be sure you are ready as early as possible to give you and your co-workers plenty of time to be prepared and then stay accreditation ready every day.