Over 98,000 DME providers became accredited or re-accredited in 2008 and 2009. More than three-quarters of them became accredited for the first time. That means three out of four providers on a triennial cycle will be going through their first re-accreditation survey in the next 18 months. What are the common problems found on survey, and when do you need to get started on your renewal?
- Common Situations
Here are a few commonalities that can cause you to fall behind in maintaining your accreditation requirements or that pose problems for renewal:
The person who was coordinating/managing all of this no longer works here.
We were part of a group process and now need to renew on our own. (This is very common for pharmacies that were accredited by NABP.)
We had a consultant who did everything for us, and that person is no longer available.
We were unhappy with the way we were treated by our accreditor. We want to change but don't know how.
All of these issues are manageable; you just need to get started on some of the main components and give yourself plenty of time.
Because CMS is now enforcing an accreditation “expiration” date, your accreditor must now conduct your re-accreditation visit well in advance of that date. If there are deficiencies found on survey, you need adequate time to correct them, file a plan of correction, have the plan approved, complete a re-visit (if needed) and successfully be re-accredited in adequate time to avoid a lapse or gap in your accreditation status.
You must begin the renewal process nine to 12 months prior to your “expiration” date in order to have adequate time. If you want to change accreditors, allow extra time to complete the new accreditor's specific requirements.
If your accreditation is expiring within the next 24 months, get started now. Whether renewing your accreditation or changing accreditors, be sure to contact the organization early in the process for their guidance on planning your specific timeline.
It may be a blur since it happened oh-so-long ago, but there are many requirements you must maintain in order to be accredited. Here are a few of the items/tasks to review, no matter who your accreditor is:
- Your Performance Improvement (PI) Program
It's easy to stay current with your PI requirements — and it's just as easy to let them get away from you. Make sure you are tracking the required indicators listed in the Final Quality Standards, including: customer satisfaction and complaints (daily and weekly); frequency of billing/coding errors (monthly and quarterly); adverse events to beneficiaries due to inadequate service(s) or malfunctioning equipment and/or item(s) (as they occur); and documentation of patient and staff infections (monthly).
Once you've been accredited, keep your personnel files current by auditing them a few times a year and creating a tickler file for those things that expire and need to be updated, such as professional licenses. For all of your staff who have been around for years, make sure you have annual evaluations and annual competency reviews in their files (as needed).
For staff members hired since your last accreditation visit, make sure they complete all of the elements of your orientation program and that this is documented in their file.
Documentation is one of the most important pieces of your business. Ensure that you have signed copies of the complete paperwork your customers receive. You should also have complete physician orders for all items. Now that we know physician notes are going to be required for audits, start gathering that documentation up front.
A consultant can help you efficiently review and evaluate any deficiencies that need to be ad- dressed before the accreditor arrives for your onsite visit. A consultant should not be your sole means of meeting the requirements, however. You can use a consultant to ensure that your process is complete and thorough so you don't have any unexpected trouble renewing your accreditation — but do it well in advance of your required renewal.
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. You can reach her at 301/896-0193 or through www.capitalhealthcaregroup.com.
