Maintaining Continued Compliance

The Centers for Medicare & Medicaid Services (CMS) requires providers to, “remain in substantial compliance with Medicare program requirements as well as State law.” This means that CMS expects accredited organizations to have continued compliance rather than cyclical compliance. Last year, many HME and DME companies had their second triennial accreditation renewal, because so many of them were initially accredited to meet the 2009 mandatory requirement. Now that your accreditation has been affirmed for the next three years, it is the perfect time to prepare for keeping your accreditation compliance in shape going forward.

Plan now to better maintain your accreditation, either through a maintenance program that your accreditor offers, or by creating and utilizing checklists that are appropriate at six months, 12 months, 24 months and 30 months in preparation for your accreditation renewal to occur before 36 months have passed.

Always use a checklist at each interval that ensures you are in compliance with all applicable local, state and federal regulations. A checklist is not intended to replace your own comprehensive review of accreditation or licensure standards, nor does it guarantee a successful accreditation decision. Make your checklists reasonable and realistic based on the following items, which are consistantly reported by accreditors as routine deficiencies.

Start with your last Plan of Correction (POC). Ensure that all deficiencies that were found have been fully corrected and that all corrective activities have been implemented and are being monitored. Your accreditor always starts your new triennial review by examining your last accreditation POC and looks to make sure you have implemented all corrective activities.

Ensure that your PI/QI data has been collected quarterly for each of the required categories. This is not an activity that you can do only every three years in preparation for your survey—you must conduct these activities on an ongoing basis. Make sure that items in this data set (such as customer satisfaction surveys) are a part of your everyday operations.

Annual competencies in staffing are a commonly deficient area in accreditation testing. Create a list that you will be able to stick to for your onboarding and annual renewal tasks, and get those competencies complete upon hire and update them annually. This is a major deficiency among providers who may complete competency assessments for new hires, but fail to do so each year for current employees. The best way to accomplish this task is by not focusing on hire dates, but to schedule an annual renewal week for all employees during a quiet business month—regardless of how long they have been with you. Get all renewals done for all staff in one week each year, and then you won’t have to worry about the task getting away from you.

Ensure that all business and HME licenses for each state where you operate are prominently displayed and current. Include those states that products are mailed to as well. Also monitor surety bond and insurance documents to make sure they are current and available for review.

Are you aware that Material Safety Data Sheets (MSDS) are now known simply as Safety Data Sheets (SDS)? Ensure that you have these on hand and that they are current and complete for all chemicals used in the operation, whether in the office or in vehicles.

Every organization must maintain proper records of all grievances and complaints and investigations and outcomes. Have the documentation that these are all appropriately reported to leadership and that all are tracked through your Performance Improvement Program.

Criminal background checks, documentation of proof of Office of Inspector General (OIG) exclusion list checks and national sex offender registry checks are required by the various accreditors and by your state licensing agencies. It is amazing how these tasks can fall through the cracks, even though they have been required (and generally conducted) for years on all employees who have direct client contact. Make sure that, in addition to direct care staff, personnel with access to client records have a criminal background check and an OIG exclusion list check completed when required, as well.

Physical building issues that must be monitored include smoke detectors, fire alarms and fire extinguishers that are present and placed in secure areas. These items must be inspected, maintained and tested on a regular basis as recommended by the manufacturer. A fire drill and an emergency-preparedness drill must be completed annually. Make sure all exits are clearly marked, illuminated (when possible) and that escape routes are posted. Make sure a first aid kit is available and of appropriate size (check annually for any expired products) and that an eyewash station is available (check for expiration date).

This is not a complete list, but it is a good start and highlights those items often found as deficiencies by surveyors from the major accreditation organizations. Add your own items to the checklist. Check to see what resources your accreditor provides, as many of them offer comprehensive checklists for your use. An additional best practice is to have an outsider conduct a mock survey at approximately 24 months to evaluate that everything is in good shape—with plenty of time to make any needed corrections before your next renewal.