Unannounced Surveys

Now that we are in the final months before CMS’ accreditation deadline Sept. 30, you can expect your unannounced survey any business day. Review the following four main areas to make sure your company is prepared.

1. Administrative Functions During the unannounced site survey, the surveyor will make sure you are compliant with the accreditor’s standards. Many accreditors have administrative standards that require such items as an organizational chart, committees that must be in place, maintaining a compliance program and inventory control, preventive maintenance and infection control and safety processes. Infection control and safety items include emergency and disaster plans, the process you follow for cleaning and repair of items and more, such as fire safety (fire extinguishers, exit routes, fire drills) and OSHA issues. No matter how small your business, these are required items, and the surveyor must take time to review your Policy and Procedure Manual and any supporting documents that show how you meet the requirements. The physical walk-through of your facility will include a visual review of the items above, as well as talking with staff to observe that your processes and procedures are followed.
2. Performance Improvement CMS and its accreditors require that you implement a performance management plan to measure outcomes of customer service, billing practices and adverse events. At a minimum, you should measure: beneficiary satisfaction and complaints; timeliness of response to questions, problems and concerns; impact of business practices on the adequacy of beneficiary access to items, services and information; frequency of billing/coding errors; and adverse events to beneficiaries due to inadequate service(s) or malfunctioning equipment and/or item(s) (e.g injuries, accidents, signs and symptoms of infection, hospitalization). Surveyors coming into your company will expect to see the data collection tools you use to collect this information, the reports you create from this data, the review your Quality Committee performs with these reports and the plans for changes or improvements you make as a result. Having this data easily available in one central place can expedite the review process.
3. Information the Customer Receives The accreditor has to ensure that you are providing complete and accurate information to your customers. Payers such as CMS require that providers teach the customer how to use the equipment. Your accreditor wants to see what written materials the customer receives from you that are used for instruction at the initiation of service. The accreditor also wants to make sure you provide all necessary documentation to the customer, which not only includes the educational materials but the items that meet regulatory compliance, such as an Assignment of Benefits, a copy of the (now) 25 Supplier Standards, a document that outlines Customer Rights and Responsibilities, etc. The surveyor generally reviews a sampling of your client records to ensure that you have documentation that the proper items were received at the first point of service.
4. Personnel Files for Your Staff Each accreditor requires that providers have an individual personnel file for each staff member with a list of items the provider is required to collect. Each accreditor is different, but the types of items they require include: documentation of the date of hire; evidence there was an interview in the hiring process; a complete background check or results of drug testing; driver’s license/driving record; signed job description; annual performance evaluations; completed and signed orientation checklist; a competency evaluation upon hire and annually for all staff who instruct customers with equipment, even glucometers. An adequate review of your company’s processes and files will help you properly prepare for your survey. Whether you hire a consultant to perform a review or perform the review yourself, going over these main areas and making changes or updates in advance of the unannounced survey will ensure that you will pass with minimal deficiencies or very little follow-up needed.

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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.