Accreditation Now
by Mary Ellen Conway

When you become accredited, you agree to maintain the accreditation standards for all three years, not just the few months prior to and following your triennial survey. Every accredited organization should be accreditation ready every day for an un-announced survey, but some think the three year visit comes around very quickly, especially when they have to gear up because they have let standards slip in the interim. Managing accreditation compliance can be difficult if you’re not organized and staying prepared. It does not matter who your accreditation organization is—it seems that all suppliers have the same deficiencies cited on their survey reports.

Incomplete Prescriber Orders

You must have current, correct and complete orders for each piece of equipment. The written order prior to delivery (WOPD) has been a requirement in DMEPOS since July 1, 2013. You cannot provide an item without it. You can’t correct or clarify incomplete orders after the item has been provided. So, if the prescriber’s order is incomplete, clarify the information, first. If this is an oxygen order, the prescriber’s order must designate the route of delivery (e.g., via nasal cannula) and the duration (continuous). If your state requires a new prescriber’s order annually, you must set up a process to ensure you obtain the new order in a timely fashion. HME functioned on dispensing orders for so many years, that many prescribers believe we still can. Teach your prescribers that you must have a complete and detailed order prior to delivery.

Patient Records

When your patient records are reviewed, it is very common to see an absence of patient signatures for all of the proper documentation required. Often it is found there is no proof that the patient received such things as:
  • The current Medicare DMEPOS Supplier Standards or permitted statement
  • The organization’s complaint policy/process information
  • An explanation of their financial responsibility
  • Educational materials about the item(s), which might be a manufacturer booklet or instructional page that educates the patient on the proper use of that equipment and the safety risks
  • Using a checklist that notes all of the required items a patient must receive/sign and getting that checklist signed or initialed and into the patient’s record ensures that all of the necessary paperwork has been provided with each new item delivery.


Competency is a basic tenant of accreditation and required by all agencies. Competency assessments have become crucial to ensure that staff—particularly those providing direct patient care—have the necessary training and skills to perform their job. Supervisors need to observe the performance of tasks to ensure that the employee is capable of performing them. A typical HME delivery technician will perform dozens of different deliveries of equipment needing set-up. Ensure that observation of these tasks is completed during orientation before sending a staff member out into the field. Observe annually, to ensure bad habits have not developed, skills are sharp and product and skill knowledge levels are maintained. Document competencies by item, or in an overall evaluation that includes all of the items the staff member works with. Use a form that can be kept in the staff member’s file. Assessments should be planned at regular intervals.

Personnel Files

Whether you keep paper or electronic personnel files, you must maintain them in a secure and organized manner so they will be ready for your surveyor during your unannounced survey. Audit your personnel files two or three times annually to ensure that the files are complete and up-to-date. Your accreditor’s standards will list all of the items your files must contain. These can include:
  • A completed application or resume
  • An orientation checklist showing all items covered during orientation (especially those required by your accreditor)
  • Applicable licenses with their initial and renewal verification
  • A job description—there should be a job description for every employee within the organization. The employee’s current job/duties must be in the file and may be required to be signed and dated.
  • Annual or bi-annual evaluations
  • Completed continuing education or in-service credits
When you audit your files, use a checklist to ensure that the files are complete. Auditing your personnel files on a regular basis will help you meet all the requirements for your survey.

Quality Improvement

One of the first questions you should ask yourself is, “How do I select the areas I would like to improve?” Medicare requires certain areas be reviewed, so be sure to follow the requirements, but also decide what can be the most beneficial to your operation. The concept of monitoring quality continuously is to locate, identify and correct any company weaknesses you can improve upon. These days it seems like we have to do more and more, with less and less reimbursement, thus administrative positions get cut and accreditation monitoring goes by the wayside. All providers should pay close attention to the areas that can be problematic between their on-site triennial accreditation visits. Integrating the inclusion of accreditation requirements a little bit everyday is much easier than trying to do everything all at once prior to each survey.