Preparing for an Accreditation Survey
7 basic accreditation requirements
by Mary Ellen Conway

Do you remember the first time you received accreditation? Was it when the accreditation requirement was new in 2009? Or were you accredited prior to the mandatory requirement? Regardless of when it was, you’ve been reaccredited several times since—every three years.

By now you may have already assembled a three-year history of meeting your accreditation requirements and processes, and you have processes in place to ensure that common requirements are met, such as keeping your HR files up-to-date, making sure your patient records are complete and ensuring your quality/performance improvement data is being collected and measured, and so on.

Since the majority of DME suppliers were accredited in 2009, this year, especially over the next few months, is a very busy time for all the accrediting organizations.

As you are preparing for your accreditation survey and renewal, now is a good time to revisit some basic accreditation requirements to ensure that you are survey-ready.


1. Know Your Accreditation Expiration Date

Your accreditation expires on your accreditation end date, and your accreditor has to file your status with CMS. You cannot let this expiration date pass without your renewal being in progress.

Your survey has to be unannounced (as required by Medicare), so you should be ready for an unannounced survey at least six to eight weeks (or more) before your expiration date so that you can have both adequate time to respond to any deficiencies found during your survey, and time for any needed corrections to be accepted. You don’t want to run out of time.


2. Read Your Last Survey Reports

That’s what your surveyor does. He or she reads what was going on at the time of your last survey, what your deficiencies were and how you were going to correct them.

Make sure previously cited deficiencies have been corrected and that you are in compliance with every issue cited on that survey. Be ready to show how that deficiency is no longer an issue.

3. Clean and Organize Your Delivery Vehicles

Ensure all of your delivery vehicles are clean, both inside and out, and that they are in good order. Make sure your drivers are segregating clean and dirty items. Your trucks and other delivery vehicles should be clean and organized: Make sure there are no scattered forms, that wrenches and tools are secure and clean, that alcohol hand cleaner is accessible (and used), and that all equipment is secured with straps, not bungee cords. If you transport oxygen tanks, be sure the equipment is secure in a cage that is mounted to the floor or side wall with netting overtop so that cylinders cannot become missiles if the driver were to stop short.


4. Check Your HR Files

Your surveyor may ask for a census or an organizational chart to select files for review, or he or she might give you the option of pulling files yourself. Your surveyor may ask to see the file of a newly-hired staff member to ensure that your HR files are complete for all new hires. Often HR files have forms that haven’t been completely filled out or even filed; make sure they are caught up.


5. Review Your On-Call Log

Surveyors often ask to see your on-call or after-hours log for two reasons: 1) to make sure you have one (it’s a Medicare requirement); and 2) to look for troubles or problems, especially repeat problems. Make sure your log is ready to show during your survey. Read your log as a surveyor would, looking for repeating problems, or issues from one particular staff member that occur after hours. Document the time from the receipt of the call to the time of the response and resolution. Check your accreditor’s requirements to make sure that your log shows that you are responding within the required time limit.


6. Complete Your Patient Records

Make sure that your records are easily accessible and complete, with the necessary copies of patient acknowledgment of receipt of the item; any other acknowledgment forms, including The 30 Supplier Standards, Rights and Responsibilities, Assignment of Benefits; home safety information; and more. Check your accreditor’s standards to find a list of the items you must provide and have on file.


7. Gather Your Quality/Performance Improvement Activities

Summarize all your quality improvement activities in a standard manner so that it is easy to review. This is one area where suppliers have trouble keeping up with quarterly data requirements. Put the data reports in a binder with tabs to separate the years for ease of review.

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 review. Make sure you have kept up with your requirements or the plan of correction you needed to create to address deficiencies. The goal is to be accreditation-ready every day. Your accreditor’s requirements should be built into your everyday practices to help prevent a frenzy of activities every three years.