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A better score is easier than you think
by Sandra C. Canally

In a perfect world, accreditation renewal should be the positive outcome of your day-to-day diligence in maintaining adherence to the accreditation standards—no matter which accreditation organization (AO) you use. The reality is that, as a business owner or accreditation manager, you must also deal with the challenges that can negatively impact ongoing standards adherence.

The purpose of this article is to point out some of the most common deficiencies our advisors at The Compliance Team have seen over many years of doing durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) on-site accreditation evaluations.

We make recommendations on how you can address these deficiencies now, even if you are up for renewal. At the end, we list some best practices for remaining compliant throughout the year. This can help you avoid future renewal headaches.

Before You Begin

In preparation for your on-site accreditation review, use all the resources provided by your AO: educational webinars and training, accreditation checklists, resource links and phone advisors who will answer your questions. Review the areas of deficiency from your previous on-site visit. Most AOs will (or should) review your previous scoring deficiencies to ensure you have maintained the corrective action. Talk to your AO and ask for suggestions on the best use of your time in preparing for your accreditation visit.

Deficiency Checklist

Below is a list of the common areas where we find providers struggle. In most cases, we describe the issue and the potential risk of not being compliant. We also provide options you might implement to maintain compliance moving forward. Be sure to document as much as possible and to demonstrate a clear plan for following through each year.

1. Complete an annual review of policies and procedures (P&P).
This should be done at least once a year, especially if there have been major changes in your business. New employees should receive a copy of your P&P upon hire. Ensure your policies (written or understood) match what your employees are doing. Document your review process.

2. HITECH HIPAA policies exist, specific to your organization.
HIPAA requires all health care-related businesses to protect personal health information.  Be prepared to show your AO’s representative everything you have regarding HIPAA policies, training, data breach plans and technology that your office uses (including cell phones and firewalls).

3. You have documented sources of training.
Training should be a mandatory part of new employee orientation and an ongoing process. Document training for each staff member and include it in their personnel file. Note the dates and sources of training. These include corporate training, HIPAA, Occupational Safety and Health Administration rules, Right to Know, blood-borne pathogens, fraud, waste, abuse and emergency preparedness. Set up a training plan at the beginning of each year and share it with your employees.

4. The provider reviews quality improvement (QI) goals quarterly. You can simplify this review by adding QI as an agenda item to every meeting you have with your staff, be it formal or informal. Set annual goals—different each year—and discuss them regularly, tracking how you are meeting the goals (or not) and ways you can improve. Reviewing patient complaints and patient satisfaction surveys will help keep you on track for QI and help avoid inconvenient and costly fixes.

5. The provider’s process to identify potential risks must be documented.
Risk assessment is one of the most important areas to address for any business. Risk can be to your patients and staff and your business, especially when liability comes into play. Things you can do to assess risk: Periodically conduct a walk-through of your facility and accompany your delivery drivers to identify potential risks; talk to your staff; read patient satisfaction surveys; discuss risk assessment in your staff meetings. Document the risks and how and when they have been remediated (or will be).

6. Preventative maintenance must be in evidence.
Be ready to show your surveyor evidence that you are following manufacturer guidelines for all equipment, including delivery vehicles. Options: Have manufacturer maintenance manuals next to the equipment, show a spreadsheet with maintenance dates and attach up-to-date maintenance stickers on the equipment. Not following manufacturer guidelines can have devastating legal ramifications should there be an incident in your facility or at a patient’s home.

7. There is documented fire safety training, including how to operate a fire extinguisher.
This should be self-explanatory, yet it continues to be a common deficiency. You can correct this issue now by ensuring your fire extinguishers are properly mounted and easily accessible in your facility and delivery vehicle, if applicable. Also, ensure your staff knows how to operate them properly. Include this in your annual training (No. 3 above) on emergency preparedness. is a good website to review for emergency readiness.

Best Practices

Here are three best practices to follow to help stay on top of accreditation needs.

  1. Ongoing Plan: Having an ongoing plan for staying compliant with quality standards is the easiest and most efficient way to plan for a renewal visit. Take time each January to set a plan in place for: staff meetings that include QI and P&P review, training, risk management, etc. Schedule each meeting and share plans and goals with your employees.
  2. Delegate: Wherever possible, delegate and cross-train employees. If an on-site surveyor shows up and you are not present, will your staff be able to access key documents and human resources records? Periodically check to ensure tasks are being done. Assign employees to take leadership in overseeing meetings, documentation updates, training, deficient areas, etc.
  3. Gather documentation in one location: Having documentation in one key location makes it easier for you and your staff to access and update. It also makes it easier for the AO’s surveyor to review during their visit. Documentation can include this and more:
    • Policy and procedure manuals
    • Licensing
    • Employee training checklists
    • Forms you have created for patients, wholesalers, product and service descriptions, organizational charts, P&L statements
    • HIPAA privacy notices
    • OSHA documentation
    • Employee files
    • Incident reports

Good planning and setting aside time for follow-through are keys to a successful on-site visit. Make 2024 one to celebrate!

Sandra C. Canally, RN, is founder and CEO of The Compliance Team (TCT). She is the principal architect and author of The Compliance Team’s accreditation programs, which are centered on her passionately held beliefs that every patient deserves exemplary care and that health care delivery excellence should not be difficult or costly to achieve. TCT celebrates its 30th anniversary in 2024. Visit