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:
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Beneficiary satisfaction and complaints;
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Timeliness of response to questions, problems and concerns;
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Impact of business practices on adequacy of beneficiary access to items, services, information;
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Frequency of billing/coding errors; and
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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.
