Surveyor Newsletter | 2024 No. 2 | Quality Review, SLP

Volume 2024 | No. 2

SURVEYOR

SLEEP

SECTION 4: HUMAN RESOURCE MANAGEMENT SLC4-6D

SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT SLC5-1A

Overview of the requirement:

The sleep lab’s medical director or certified sleep physician conducts monthly education for personnel. This standard is evaluated through review of training logs. Deficiencies cited lack of written evidence that the required professional was involved in the monthly education. Individual personnel files were often missing evidence of attendance.

Overview of the requirement:

The standard ensures that an individual record is maintained for each client/ patient and that the record contains specific required elements. Surveyors assess compliance through review of policies and procedures and client/patient records. Most deficiencies resulted from insufficient documentation, especially the lack of pre/post sleep study questionnaires.

Comment on deficiencies:

Comment on deficiencies:

Frequency of citation:

34%

Frequency of citation:

15%

Examples of surveyor findings:

n Client records did not contain: Pre/post study questionnaires.

Examples of surveyor findings:

n The organization does not offer monthly in-service and/or educational sessions conducted by the medical director or a certified sleep physician. n  Personnel files contain evidence that monthly education was attended, however there is no evidence that the medical director conducted the sessions. n Work with the medical director to develop and implement ongoing educational sessions conducted by the medical director for inclusion in the monthly meetings. Topics should include, at a minimum: New equipment. Facility policies and procedures. Clinical protocols. n Conduct periodic audits to ensure inclusion into the employee record.

Referral order and notes from referring physician. Appropriate order for the test performed. Type of device used for home sleep study (HST). Epworth Sleepiness Scale documentation. Emergency contact. Client information sheet completed prior to the sleep test.

Tips for compliance:

n Written policies and procedures did not indicate that HST client/patient records must include documentation of client/patient ability to understand and use the equipment/supplies provided. n  Ensure that written policies and procedures fully define the required contents of the client/patient record. n Reeducate personnel on the process for obtaining all required items for client/ patient records. Consider monitoring for these items in your PI activity for client/ patient record review. Develop and implement a protocol to clearly document the inclusion of sleep questionnaires in HST device packaging. If the questionnaires are not included in the returned device’s packaging, document in the medical record the unsuccessful attempts to receive the patient’s questionnaires.

Tips for compliance:

Consider implementing a sign-in sheet for every session and creating an internal auditing process to ensure attendance is consistently captured.

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