checking the boxes on accreditation
9 areas to review before your survey
by Mary Ellen Conway

I recently looked back into my old files and found an article that I wrote for HomeCare on re-accreditation back in 2015. For many of us, 2021 is a year of triennial accreditation renewal, and even though 2015 was years ago—and a time when the world was in a different place—the concepts to review for re-accreditation remain the same.

In this pandemic year, many suppliers have opted for a virtual survey in lieu of an on-site, in-person survey. Tim Safley of the Accreditation Commission for Health Care reviews the process of a virtual survey in an article in HomeCare’s April issue that you can re-read to get an idea of how it works.

If you do opt for a virtual survey, there will be a few things you must be prepared to provide:

  • A stable internet connection
  • A designated computer (with that stable internet access) where you can access all files and documents that you will be providing for survey, including access to all personnel files and documentation
  • The GoToMeeting, Zoom or other video chat program you will be advised to have available once you agree to a virtual survey with your accrediting organization
  • A cellphone or tablet with a camera that will allow you to virtually show the surveyor around your office for mobile live views or a tour of your office showing the exterior and interior, including where your files are stored, your warehouse, etc.

Basic Survey Readiness

Things have changed since you were first accredited, so you should now be accustomed to the accreditation process and be ready to present a three-year history, whether your re-survey will be virtual or in person. Here are nine tips to get you started.

1. Start early.

Your accreditation expires on your accreditation end date and your accreditor has to file your status with the Centers for Medicare & Medicaid Services (CMS) each month. Even if you are doing a virtual survey, your survey must be unannounced, so you should be ready for an unannounced survey six to eight weeks before your expiration date so that you have adequate time to respond to any deficiencies found and time for your corrections to be accepted. All of these activities should occur as early as possible.

2. Read your last survey report.

That’s what your surveyor does! They will check to see what was going on at the time of your last survey, what your deficiencies were and your plans to correct them. Make sure all of those deficiencies have been corrected and that you are compliant with every issue for which you had been previously cited.

3. Clean & organize your delivery vehicles.

Make sure all of your delivery vehicles are clean both inside and out and that they are in good working order. Ensure that your drivers are separating clean and dirty items, that cling stickers with reminders for oil changes are up to date, that wrenches and tools are clean and secure, that alcohol-based hand sanitizer is accessible, and that all equipment is secured with straps rather than bungee cords. Ensure that private health information is secured and that extra forms aren’t scattered throughout the vehicle. If you transport oxygen tanks, be sure they are secure in a cage that is mounted to the floor with netting over the top so they cannot become missiles if the driver were to suddenly stop.

4. Check your human resources (HR) files.

Your surveyor may ask for a staff census or an organizational chart to select files for review, or they might give you the option of pulling files yourself. A virtual survey requires you to be able to upload these files or individual documents securely so the surveyor can review them. The surveyor likes to see the hire date of staff and may ask for the file of a newly hired staff member, so be sure that your HR files are complete for all new hires. You may find that forms haven’t been placed into the individual personnel file yet, so make sure these new hire files are complete in anticipation of your surveyor’s review.

5. Note your educational requirements.

Make sure you have documentation of all of the educational requirements your staff has met each year. This can be done in a variety of ways:

  • An annual calendar showing the dates and title of the classes held that might include the course title, handouts, agenda, speaker, pre- or post-tests or attendance sheets
  • Certificates of completion/copies of attendance reports in the individual staff member’s file
  • Copies of sign-in sheets for a particular class kept together by year

There is no single best way to prove that the staff has completed their requirement, as long as you have the documentation that shows it was completed.

6. Review your on-call & complaint logs.

Surveyors often ask to see your on-call or after-hours log and your complaint logs for two reasons: to make sure you have one of each (it’s a Medicare requirement), and to look for troubles or problems, especially repeat problems that are frequent complaints or that occur after hours.

Read your logs as a surveyor would, looking for recurring problems or issues from a particular staff member. In your after-hours log, make sure you have documented the time from the receipt of the call to the time of the response, as you are held accountable to your policy requirements for responding to a call within a certain amount of time. The same applies to your complaint log, which is also required by Medicare. Check your accreditor’s requirements to make sure that your logs show that you are responding to after-hours calls and complaints within the required time limit.

7. Provide patient records.

Make sure that your records are easily accessible and complete, with all of the necessary copies of the patient’s acknowledgement of receipt of items, such as a statement regarding (or copy of) the 30 supplier standards, patient rights and responsibilities, the assignment of benefits, instructions for safe use of the item(s) provided, basic home safety information and more. Check your accreditor’s standards and use the checklists they provide to review their list of the items you must have on file. Look into digital options for ensuring forms are filed on delivery and easily stored.

8. Update your emergency plan.

Did you change or revise your emergency plan this year? Has it changed because you have people who are now working from home and no longer in the office? Make sure it is up to date and
has been checked annually and revised as needed.

9. Document your quality & performance improvement activities.

Stop procrastinating and sit down and summarize all of your quality improvement activities. This is one area where suppliers do not keep up with the data quarterly. Make sure it has been gathered neatly in one place (a designated binder works well) and is ready to be reviewed, whether in person or virtually for each quarter during the last three years.

This is not meant to be a comprehensive list of preparation activities, just a quick reminder of some of the big items you need to focus on. You really should be accreditation-ready every day, but we all gear up when a re-accreditation cycle is approaching. Your accreditor’s requirements should be built into your daily practices and, as long as you keep up with them, there shouldn’t be a frenzy of activities every three years. Make sure you are ready as early as possible to give you and your coworkers plenty of time to be prepared.

Mary Ellen Conway, RN, BSN, is chief compliance officer for US Med and a member of the HomeCare Editorial Advisory Board. She can be reached at