The Lights May Be On

In the mad dash over these last few months before the DMEPOS accreditation deadline, the surveys are fast and furious. Because CMS requires that surveys be unannounced, a surveyor can appear at your doorstep any time during your business hours. Although it happens infrequently, your survey could occur on a Saturday if that is a day you are open for business.

Remember that everyone at your company should be aware of your accreditation activities. I’ve had calls in recent weeks describing problems on survey because the “person” who did all the work was not available that day. There’s nothing wrong with having one person or a small team be responsible for the preparation activities, but a company cannot operate in a vacuum.

If you are a small DME provider or a pharmacy awaiting your survey, review the following items to make sure this does not happen to you.

• The organization is getting accredited, not a person or a team. This cannot be the responsibility of one person alone. This is the No. 1 rule to remember. Accreditation reviews your business’ processes, functions and procedures. It ensures you are compliant with payer and licensure requirements. Accreditation requires that you have a standardized performance improvement program. Meeting accreditation requirements is the responsibility of everyone who works in the company, whether he or she is a driver, a customer service representative, billing clerk or manager. There are business owners who are angry that they have to get accredited. They assign one person to do all the work and give them very little support. If this is your perspective as an owner, you have a disaster waiting to happen. Your frustration is with the multitude of criminals who came into this business and made it difficult for everyone. Don’t rebel against your accreditor. Those organizations didn’t go to CMS and ask to put this requirement in place. You don’t want to fail this process and not be accredited before the deadline, nor do you want to pay for repeat visits by the surveyor to see if you are compliant.
• More than one person needs to know where to find (and have access to) all of your materials on the day of survey. On the day of your survey, some of the major items your surveyor will need to review are your policy and procedure manual, the materials you provide to your customers and the signed documentation from customers that you keep on file. He or she will also review your staff personnel files. Your surveyor needs to observe your process with customers and will ride along on deliveries or, in the retail setting, he or she may contact your customers by phone. If the surveyor is unable to review these items, you are going to have difficulty surviving the survey successfully. If your personnel files are locked up and only accessible by one person with a key who is not available that day, you have a problem.
• Review and rehearse with the staff as much as possible. The more you “rehearse” the types of questions your staff may be asked and advise them about what the surveyor needs, the easier it will be for employees to answer questions and understand the process — and the less stressful the entire event can be.

No surveyor (of whom I’ve ever been aware) is going to ask your delivery technician, “What’s on page 146 of your Policy and Procedure Manual?” But it is reasonable for a surveyor to ask what kind of orientation the tech received, what kinds of ongoing education is offered, whether he or she has received Hepatitis B immunizations or what kind of performance improvement activities the organization conducts.

Your tech should be able to speak to each of these from firsthand experience. He should be able to explain his orientation, what in-services are offered or what online educational programs he is required to complete. If he was offered Hep B, he either accepted or declined the vaccine. He certainly knows the components of the Performance Improvement program that apply to him; he may not know that the company maintains a billing and coding errors log, but he knows you are measuring customer satisfaction and complaints, doesn’t he?

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.