Volume 2024 | No. 2
SURVEYOR
SLEEP
SECTION 3: FISCAL MANAGEMENT SLC3-4A
SECTION 2: PROGRAM/SERVICE OPERATIONS SLC2-4B Overview of the requirement:
Overview of the requirement:
The client/patient is advised of their financial responsibility for care/service at, or prior to, the receipt of care/services. Compliance is evaluated through interviews and review of client/patient records. Most deficiencies were cited due to lack of documentation of compliance. Surveyors noted that organizations surveyed for reaccreditation had repeat deficiencies in this area, reflecting challenges with sustained compliance.
Sleep lab clients/patients are provided with information that covers how to communicate a grievance/complaint to the organization, relevant state agencies, and ACHC. Compliance with this standard is evaluated through review of new client/ patient admission packets and client/patient records. Deficiencies were cited for repeated failure to provide essential contact information, lack of adherence to regulatory requirements, and absence of clear processes for informing patients about handling complaints.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
14%
Examples of surveyor findings:
n Client/patient records did not have evidence that the client/patient was informed of charges and the expected reimbursement from third-party payors. n Upon interview, a patient confirmed that no information had been provided about any possible charges after payment is received from insurance. n Records did not document that the client/patient was informed of the charges for a separate professional fee. n Provide clear explanations of charges and expected reimbursements at the initiation of services, and document acknowledgement of these communications. n Develop and implement a process to ensure patients are consistently informed about financial details.
Frequency of citation:
20%
Examples of surveyor findings:
n Written information provided to the client/patient did not include the state regulatory body’s hotline numbers, hours of operation, and the purpose of complaint resolution systems. n Client/patient records did not contain proof the patient received contact information for ACHC if they wish to voice a concern or complaint regarding the care received at the sleep center. n There was no evidence the client had been informed how to contact the SLC, state agencies, and ACHC concerning a complaint or grievance. n Provide each client/patient with an admission packet detailing the complaint resolution process, including ACHC’s phone number and contact information. (Note: the requirement to include ACHC’s contact information is not applicable to organizations that are not yet accredited.) n Maintain documentation of receipt of information within client/patient records; reeducate personnel as necessary. n Develop and implement a process to ensure all clients receive information regarding investigation, and resolution of patient/client complaints about care/ services provided. Conducts audit to ensure ongoing compliance.
Tips for compliance:
Tip s for complianc e:
Do you have an admissions checklist? A checklist may help ensure that staff is including all required elements.
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