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Volume 2025 | No. 2
Quality Review Edition THE Accreditation Resource for Data Nerds SURVEYOR
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
03 Corner View
04 From the Program Director
06 Frequent Deficiencies in DMEPOS
BOARD OF COMMISSIONERS
LEADERSHIP TEAM
Brock Slabach, MPH, FACHE Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CEO, MSMP ANESTHESIA SERVICES, LLC
Leonard S. Holman, Jr., RPh Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES
John Barrett, MBA Officer-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM
Matt Hughes VICE PRESIDENT, COMMUNITY CARE SERVICES Jonathan Kennedy, CPA, MBA VICE PRESIDENT, FINANCE AND CORPORATE SERVICES
Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO
Mark S. Defrancesco, MD, MBA, FACOG Secretary WOMEN’S HEALTH CONNECTI CUT/PHYSICIANS FOR WOMEN’S HEALTH (RETIRED)
Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
Jennifer Burch, PharmD OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS
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Volume 2025 | No. 2
SURVEYOR
CORNER VIEW WITH PRESIDENT & CEO, JOS É DOMINGOS
You made a great decision when choosing ACHC to accredit your organization. Whether you are new or have years of experience with us, I am confident that you have already felt first-hand our intense focus on customer service. Real support that builds your team ACHC doesn’t engage in “accreditation theatre” through complex scoring rubrics or punitive surveys that give an illusion of rigor without adding any true value for your organization. Instead, we focus on real support designed to close any gaps between your current state and full standards compliance. We are known as Accreditation Nerds for our genuine belief in—and passion for— the efficacy of accreditation to enhance quality and safety in healthcare organizations. But we know it works best when those organizations understand and embrace continuous performance improvement. The Quality Review edition of Surveyor is an excellent place to start. This publication is a resource, demonstrating how ACHC program teams work to help you develop individual expertise within your organization, while recognizing that your staff may have varying levels of experience and knowledge of accreditation standards.. The standards listed are the most frequently noted as noncompliant on recent surveys and the compliance tips provided are divided into categories to make them useful for individuals across a range of roles and expertise. “Accreditation Nerd Newbies” are just that: individuals new to the process of compliance with accreditation standards. ACHC uses a Plan- Do-Study-Act framework to organize standards. Even a “simple” standard may include multiple
elements for full compliance. Under Compliance tips for Nerd Newbies, we offer a clear summary of the expectations for each standard. “Accreditation Nerd Apprentices” understand the concepts of meeting and maintaining standards. Compliance tips for Nerd Apprentices focus on using data on hand to continuously assess how well your organization is performing. Finally, “Accreditation Nerd Trailblazers” are those individuals who are passionate about maximizing their organization’s capacity for excellence. They are enthusiasts who eagerly share their knowledge with colleagues to create a path forward. Nerd Trailblazers thrive on the goal of continuous improvement. Compliance tips for Nerd Trailblazers cover best practices designed to level up your organization. These tongue-in-cheek categories are our way of saying that it’s possible to approach accreditation seriously without being humorless. When we say that we want to help you develop your staff into a team of Accreditation Nerds, you immediately understand the goal. Partnership you can rely on Once your organization is ACHC-accredited, we become your partner, dedicated to meeting your needs. ACHC’s staff of Accreditation Nerds— account advisors, surveyors, clinical educators, quality and regulatory, and other experts— thrive on being helpful. Review the information on the pages that follow confident that we’re ready to dig in to answer questions, provide feedback, offer suggestions, and direct you to any additional resources you need.
MISSION STATEMENT
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
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Volume 2025 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
DMEPOS
A survey with no findings—no identification of non-compliance—is exceedingly rare, and that knowledge can be daunting. The important takeaway when exploring deficiency data is growth and improvement. This Quality Review edition of Surveyor identifies and analyzes the most challenging standards for the ACHC DMEPOS Accreditation Program. This year’s data span initial and renewal surveys conducted between June 1, 2024, and May 31, 2025.
DMEPOS Trends This is my first Quality Review issue of Surveyor since joining ACHC to lead the DMEPOS team. I have found it to be a valuable resource. For me, it offers insight into where we may need to provide additional training to ensure that suppliers have a full understanding of what compliance looks like in practice. For a customer, it offers actionable tips to improve their organization. The ten standards identified in this publication were noncompliant on over 15% of DMEPOS accreditation surveys. Three of the ten are related to the provision of information to clients/patients ( DRX2-2A , DRX 2-4B , and DRX2-4C ). Compliance with DRX2-4B and DRX2-4C has improved since 2022 when this cohort of organizations was last surveyed. However, surveyed organizations now have more deficiencies related to DRX2-2A with a rate of 18% noncompliance compared to 15% three years ago. Missing documentation and inadequate staff training are the usual culprits behind these citations. We urge you to assess competencies regularly and audit your intake processes against both ACHC Standards and the CMS Quality Standards for DMEPOS. This year’s most frequently cited deficiency is DRX7-12D , which has been the case for five years running. The good news is we are seeing significant improvement over time. In 2022, this
standard was deficient on 42% of DMEPOS surveys. This year I’m pleased to report a decrease to 30%—but that number is still a bit high. DRX7-12D details requirements for cleaning, storage, transportation, delivery, and setup of equipment. Proper separation areas in both warehouses and delivery vehicles continue to miss the mark. Storage and delivery of oxygen tanks are also primary sources of concern. Compliance with the requirements of DRX7-12D will increase greatly with consistent audits of warehouses and delivery vehicles. I encourage you to create learning opportunities by conducting mock audits with your team. Incorporate the requirements into your PI Program. Emphasize the importance of this standard with every member of your staff. In other areas, accredited suppliers are making significant strides. When we compare rates of noncompliance with those from three years ago, DRX6-3C has dropped from 25% to 18%. DRX7-4A has greatly improved, from 29% to 17%. DRX4-8A is perhaps the most impressive, with 36% non-compliance in 2022 lowered to 16% in this year’s report. These achievements show that accredited suppliers are committed to ongoing improvement, and I’m proud of the progress that has been made.
Changes in 2026 CMS changes to the requirements for DMEPOS reimbursement are the subject of current discussion and concern across organizations of all sizes. The biggest shift is the change from a three year survey cycle to an annual survey beginning January 1, 2026, for both new and renewing organizations. If you were surveyed this year, your accreditation term will not change. Annual surveys will begin with the expiration of your current accreditation. Despite the regulatory change, ACHC’s educational approach remains consistent. I encourage you to frame the more frequent surveys as an opportunity for a closer partnership.
Together, your organization and ACHC will be able catch compliance errors at the earliest possible moment, when they are often easiest to correct. That means less time remediating deficiencies, and more time making meaningful improvements to impact the quality of your patient support, and the sustainability of your business. As I continue my journey leading ACHC DMEPOS Accreditation, I look forward to your feedback on how my team can better support your success. Please reach out at any time.
Deborah Panza, BS, RRT, RPSGT Associate Program Director
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DMEPOS
SECTION 1: ORGANIZATION AND ADMINISTRATION DRX1-4A Frequency of the citation: 22%
Overview of the requirement: A designated individual is responsible for the organization’s programs and services and accountable to the governing body. In the absence of the manager/leader, another individual is authorized, in writing, to act as the manager/leader. Comment on deficiencies: Compliance is evaluated through review of personnel files, orientation records, and direct observation. Most deficiencies were cited because a temporary leader was not assigned and/or their duties are not defined in the applicable job description. Examples of ACHC Surveyor findings: ■ A temporary leader has not been appointed to act in the absence of the leader. ■ The duties of temporary leader are not included in the appropriate job description.
CLINICAL LABORATORY ACCREDITATION
Services
Distinctions
Home/Durable Medical Equipment Medical Supply Provider Complex Rehabilitation & Assistive Technology Supplier Fitter Community Retail with or without Fitter*
Clinical Respiratory Patient Management Custom Mobility
*This service is for licensed retail pharmacies that sell commonly used durable medical equipment and supplies. Community Retail Accreditation does not cover the provision of prescription medications or vaccines.
FREQUENT DEFICIENCIES FROM DMEPOS SURVEYS
Compliance tips for:
■ This standard requires documentation for: ٝ A designated manager/leader. ٝ A temporary leader.
Nerd Newbies (understand the requirement)
60%
■ A job description specifies the responsibilities of the manager/leader. ■ The temporary leader is authorized in writing to act in the absence of the manager/leader. The job description for this individual also specifies responsibilities applicable to the role.
50%
40%
■ Audit personnel files to confirm that:
Nerd Apprentices (audit for excellence)
ٝ Job descriptions are present for both the designated manager/leader and the temporary manager/leader. ٝ The job descriptions for these individuals address all applicable responsibilities. ■ Review policies annually to ensure a temporary leader is designated and that the designation is still accurate. ■ If there have been changes, modify the policy and or job description as needed.
30%
20%
10%
Nerd Trailblazers (prepare the path for others)
0% DRX1-4A DRX2-2A DRX2-4B DRX2-4C DRX4-7A DRX4-8A DRX5-1A DRX6-3C DRX7-4C DRX7-12D
Organization and Administration
Program/Service Operations
Human Resource Management
Provision of Care and Record Management
Risk Management: Infection and Safety Control
Quality Outcomes/ Performance Improvement
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DMEPOS
SECTION 2: PROGRAM/SERVICES OPERATIONS DRX2-2A Frequency of the citation: 18%
Compliance tips for:
■ This standard applies to the creation and distribution of client/patient rights and responsibilities. Client/patient rights include several required components. The organization protects and promotes the exercise of these rights. The organization also develops a statement of client/patient responsibilities. ■ Written policies and procedures outline the process of providing the information to clients/patients prior to furnishing care or during the initial evaluation visit prior to the start of care. ■ The organization must document the receipt of client/patient rights and responsibilities. ■ Personnel receive training on the provision of this information, both during orientation and at least annually thereafter. ■ Audit information provided to new clients/patients at least annually to ensure that the rights being provided are current with ACHC Standards. ■ Review client/patient records to ensure that there is documentation of receipt of client/patient rights and responsibilities. ■ Initial and annual education on patient rights may not be adequate. Assess competency through testing. ■ Conduct mock survey interviews and ask personnel to describe at least 3-4 client/patient rights.
Nerd Newbies (understand the requirement)
Overview of the requirement: The organization provides the client/patient with a list of rights and responsibilities in advance of furnishing care or during the initial evaluation visit before the initiation of care. Comment on deficiencies: Compliance is evaluated through review of policies and procedures, client/patient records, and the client/patient rights and responsibilities statement. Surveyors may also interview staff to assess knowledge of the requirement. Surveyors cited deficiencies related to several aspects of the standard: proof of receipt, staff knowledge, and accuracy of the list itself. Examples of ACHC Surveyor findings: ■ Client/patient records did not document receipt of their rights and responsibilities. ■ The organization’s statement of client/patient rights and responsibilities was missing the right to: ٝ Be informed of any financial benefits when referred to an organization. ٝ Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source. ٝ Voice grievances/complaints regarding treatment or care. ٝ Choose a health care provider, including an attending physician. ■ Upon interview, personnel could not identify or discuss 3-4 patient rights.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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DMEPOS
DRX2-4C Frequency of the citation: 18%
DRX2-4B Frequency of the citation: 16%
Overview of the requirement: At the time of admission, the organization provides the client/patient with documentation detailing its process for receiving, investigating, and resolving complaints. The documentation includes how to contact the supplier, ACHC, and, when required by the state, the appropriate state agency. Comment on deficiencies: Compliance is assessed through review of client/patient records, new client/patient admission packets, and policies and procedures. Most deficiencies resulted from missing elements in the complaint information and inadequate documentation of receipt. Examples of ACHC Surveyor findings: ■ Client/patient records do not contain proof of receipt of the organization’s complaint process. ■ Complaint information provided to clients/patients does not include: ٝ Telephone number. ٝ Contact person. ٝ The process for receiving, investigating, and resolving grievances/complaints. ٝ Information on how to contact ACHC with a complaint. Compliance tips for:
Overview of the requirement: When handling Medicare beneficiary complaints, the organization follows the process outlined in the CMS Quality Standards for DMEPOS suppliers. Within five business days of receipt, complaints are acknowledged and investigations begin. Beneficiaries are notified with a written response within 14 days. Comment on deficiencies: Surveyors assess compliance through review of grievance/complaint records and by interviewing staff. Most deficiencies were cited due to lack of compliance with required time frames.
Examples of ACHC Surveyor findings:
■ There is no evidence that Medicare beneficiaries: ٝ Receive written notification of the results of the investigation of their complaint within 14 days. ٝ Are notified within 5 days that their complaint has been received and is being investigated. ■ The manager and performance improvement (PI) coordinator were not aware of the required time frames and methods for responding to Medicare beneficiaries after being informed of a grievance/ complaint/concern. Compliance tips for:
■ CMS Quality Standards require supplier organizations to notify beneficiaries of two key phases of a complaint investigation: ٝ The complaint is acknowledged and investigations are under way (within five business days of receipt.) ٝ The investigation has an outcome and a written response (within 14 days). ■ The organization maintains records of all grievances/complaints, client/patient notifications, investigations and outcomes. This information is reported to leadership through the performance improvement (PI) committee.
Nerd Newbies (understand the requirement)
■ The organization provides all clients/patients with information listing a telephone number, contact person, and the organization’s process for receiving, investigating, and resolving grievances/complaints about its services/care. ■ ACHC’s telephone number must be provided. (This requirement is not applicable to an organization if this is its first ACHC survey.) ■ At least annually, review information provided to new clients/patients to ensure that the complaint information is current with ACHC Standards. ٝ Check specifically for details on how to file a complaint with the organization or ACHC. ■ Audit client/patient records to ensure that there is documentation of receipt of how to file a complaint.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Routinely audit complaint records to ensure that: ٝ Timeframes are being met.
Nerd Apprentices (audit for excellence)
ٝ All complaints received by personnel are properly documented, investigated, and communicated to clients/patients. ■ Are all personnel responsible for handling complaints are aware of the requirements? ■ Check for compliance frequently. ■ Educate to ensure retention.
■ Reeducate personnel on the importance of:
Nerd Trailblazers (prepare the path for others)
ٝ Providing compliant information to clients/patients. ٝ The policy for handling complaints. ■ Review the client/patient intake process. Is there a way to document provision of complaint information in the client/patient record?
Nerd Trailblazers (prepare the path for others)
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DMEPOS
Compliance tips for: Nerd Newbies
■ Competency assessments are required for all personnel who set up, train, clean, test, repair, and/or educate the use of equipment and/or supplies. Competencies are conducted: ٝ initially during orientation. ٝ prior to providing a new task. ٝ annually. ■ This includes all personnel who perform these services, even if provided in the store or if they perform them infrequently. If customer service or management personnel complete a new setup in the store, or on their way home from work, they must also have competency assessed and documented. ■ Audit applicable personnel files to ensure that competency is reassessed and documented annually and prior to providing a new task, as well as during the training and orientation process. ■ Confirm that on-call personnel are not performing duties independently until competency has been assessed and documented. ■ Review policies for inclusion of your organization’s Competency Assessment Program. ■ Place reminders on a calendar or incorporate annual competencies into the annual performance review process. ■ If your organization has only one person performing the duties (e.g., fitter, ATP, RT), consider asking industry professionals such as manufacturer sales reps to complete the competency assessment. Mock demonstrations can be assessed if direct care with clients is not possible.
(understand the requirement)
Nerd Apprentices (audit for excellence)
SECTION 4: HUMAN RESOURCE MANAGEMENT DRX4-7A Frequency of the citation: 17%
Nerd Trailblazers (prepare the path for others)
Overview of the requirement: The organization designs a Competency Assessment Program for all personnel who set up, train, clean, test, repair, or educate on the use of medications, equipment, and/or supplies. Comment on deficiencies: Compliance is evaluated through review of policies, procedures, and competency assessments. Most deficiencies resulted from missing documentation of competencies. Examples of ACHC Surveyor findings: ■ Written procedures do not address determining competency for personnel who set up, train, and/ or educate on the use of medications, equipment, and/or supplies. ■ Personnel files did not contain documentation of competency assessments conducted during orientation, prior to providing a new task, and annually. ■ Policy stated that ongoing staff competency assessments would be every 36 months instead of annually as required.
DRX4-8A Frequency of the citation: 24%
Overview of the requirement: A written education plan is established for each classification of personnel. The plan includes training provided during orientation as well as ongoing in-service education. Comment on deficiencies: Compliance with the standard is assessed through review of policy and procedures, response to interviews, and review of training/in-service logs. Most deficiencies were cited because required annual trainings were not completed. When trainings had been completed, surveyors noted that required topics were missing.
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DMEPOS
Examples of ACHC Surveyor findings: ■ Personnel files did not contain evidence of annual training. ■ There was no evidence of training on the following required topics: ٝ Handling complaints. ٝ Emergency/disaster training. ٝ Patient-specific needs (formerly cultural diversity). ٝ Communication barriers.
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT DRX5-1A Frequency of the citation: 28% Overview of the requirement: Each client/patient has an accurate, complete record that includes all required items. Comment on deficiencies: Compliance with the standard is assessed through review of policies and procedures and patient records. Most deficiencies resulted from the omission of an emergency contact.
Compliance tips for:
■ Ongoing in-services and trainings include a variety of methods and resources that cover, at minimum, nine topic areas defined by the standard: ٝ Emergency/disaster training. ٝ How to handle grievances/complaints. ٝ Infection control training. ٝ Patient-specific needs. ٝ Communication barriers. ٝ Ethics training. ٝ OSHA, client/patient safety, and components of DRX7-2A. ٝ Client/patient rights and responsibilities. ٝ Compliance Program. ■ Attendance at ongoing education programs must be documented in writing. ■ Audit personnel files for documentation of completion of required annual training. ■ Confirm that attendance at every training/in-service is captured via sign-in sheet or another appropriate method. ■ Review the written education plan for inclusion of all nine required topics. ■ Set up a calendar indicating when each required in-service will occur. Schedule them throughout the year so it is not as time consuming for personnel to complete. ■ Use an online learning system (e.g., HealthTrainU) to assign courses to personnel each year. This will make course completion easy to track.
Nerd Newbies (understand the requirement)
Examples of ACHC Surveyor findings:
■ Client/patient records did not contain: ٝ An emergency contact. ٝ Initial client/patient assessments. ٝ Home assessments. ٝ Diagnosis.
Compliance tips for:
■ The client/patient record must include, at a minimum: ٝ Identification data. ٝ Names of family/legal guardian/emergency contact. ٝ Name of primary caregiver(s).
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
ٝ Name of physician responsible for care and physician’s orders. о Physician or other licensed practitioner with prescribing authority. ٝ Diagnosis. ٝ Signed release of information and other documents for PHI. ٝ Admission and informed consent documents. ٝ Initial assessments. ٝ Notice of receipt of Client/Patient Rights and Responsibilities statement. ٝ If applicable: о Ongoing assessments. о Assessment of the home. о Notice of receipt of the Medicare DMEPOS Supplier Standards.
Nerd Trailblazers (prepare the path for others)
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SURVEYOR
DMEPOS
Compliance tips continued:
Compliance tips for:
■ The organization’s PI Program identifies the process for conducting client/ patient satisfaction surveys. ■ Input from both personnel and referral sources must be included in this process. ■ This information is required by the CMS Quality Standards for DMEPOS. ■ The ACHC Standard does not define the method or frequency, but data should be collected frequently enough to identify negative trends (at least annually). ■ Review your PI Program. Does it include monitoring of client/patient satisfaction data? Is your organization obtaining input from personnel and referral sources? ■ Lead an in-service on the importance of gathering PI data. Focus on the specific components of this standard. ■ Make sure personnel understand each individual type of feedback: clients/ patients, personnel, and referral sources.
■ Review policies to ensure that documentation for delivery into a residence requires completion of a home assessment. ■ Audit client/patient records to confirm the inclusion of all applicable required elements. ■ Monitor for missing items in your PI activity for client/patient record review. ■ Ensure there is a way for personnel to document if a required element is not available. ■ Reeducate personnel on the importance of: ٝ Obtaining a diagnosis and an emergency contact for all clients/ patients. ٝ Completing and documenting a home assessment upon initial delivery or a change in the environment.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
SECTION 6: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT DRX6-3C Frequency of the citation: 17%
SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL DRX7-4C Frequency of the citation: 16% Overview of the requirement: The organization provides the client/patient with education on what to do in the event of an emergency. Comment on deficiencies: Surveyors evaluate compliance through review of client/patient records and education material. Most deficiencies were due to missing elements in the emergency preparedness information and no proof of client/patient receipt. Examples of ACHC Surveyor findings: ■ Client/patient records did not contain proof of receipt of emergency preparedness education. ■ The organization’s client/patient emergency preparedness education material does not include:
Overview of the requirement: Performance improvement (PI) activities include client/patient satisfaction surveys.
Comment on deficiencies: Compliance is assessed through surveyor review of PI reports. Most deficiencies were cited due to the lack of feedback from personnel and/or referral sources. Examples of ACHC Surveyor findings: ■ Input/feedback from personnel and referral sources has not been obtained. ■ Client/patient satisfaction surveys are being completed and input/feedback obtained from client/ patient. However, the data is not being incorporated into the PI Program.
ٝ How to contact the organization. ٝ How to handle the equipment. ٝ How to handle a missed treatment or delivery.
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DMEPOS
Compliance tips for: Nerd Newbies
DRX7-12D Frequency of the citation: 30%
■ CMS DMEPOS Quality Standards require suppliers to provide emergency preparedness information to clients/patients. The ACHC Standard defines the minimum information to be provided as how to: ٝ Contact the organization.
(understand the requirement)
Overview of the requirement: Personnel follow policies and procedures for equipment used in the provision of care/service. Implementation includes cleaning, storage, transportation, delivery, and setup. Comment on deficiencies: Evidence of compliance includes direct observation, interviews, and personnel file review. Most deficiencies were cited due to insufficient equipment segregation and missing documentation related to maintenance and repairs. Examples of ACHC Surveyor findings: ■ Areas in the warehouse were not defined for clean, dirty, and quarantined/expired products. ■ There was no eyewash readily available in the dirty equipment cleaning area. ■ Personnel who repair equipment were missing evidence of training and skill validation. ■ Equipment cleaning and function checks were not documented consistently. There was no documentation of cleaning or function checks on home fill units. ■ Routine maintenance, preventative maintenance, and repairs performed according to manufacturer’s guidelines are not being documented. ■ SDS sheets were not accessible in the delivery vehicle(s). ■ The company is not tracking lot numbers of their oxygen tanks. ■ Full and empty oxygen cylinders were not segregated ■ Oxygen cylinders are not stored securely. ■ The organization has not verified that their oxygen supplier is licensed by the state as required by Supplier Standard #27.
ٝ Handle any equipment (if applicable). ٝ Handle a missed treatment/delivery.
■ Routinely audit client/patient records for proof of receipt of emergency preparedness information. ■ Review the emergency preparedness handout and add any missing information. ■ Ensure there is a place to capture documentation of receipt of emergency education material. Revise if needed. ■ Reeducate personnel to document receipt of this information upon initial delivery/provision of service. ■ Consider adverse weather events common to your organization’s area(s) of service and plan accordingly.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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DMEPOS
NOTES
Compliance tips for:
■ This standard relates to the equipment used in the provision of care/service and addresses ٝ Cleaning. ٝ Storage. ٝ Transportation. ٝ Delivery. ٝ Setup. ■ Each component of the standard outlines specific practices that must be followed for the safety of clients/patients and personnel. Examples include: ٝ Clean and dirty equipment is separated in warehouses and delivery vehicles. ٝ Maintenance and cleaning are documented. ٝ Home assessments are conducted during deliveries. ■ Tour your warehouse to ensure proper equipment segregation. If not already present, create areas for: ٝ Separation of dirty, inoperable, and clean equipment. ٝ Separation and removal/disposal of expired products including the requirements for quarantine, product recalls, and equipment returned for repair. ٝ Proper storage for oxygen cylinders, both full and empty. ■ Routinely inspect delivery vehicles. There must be a process to segregate clean and dirty product, such as: ٝ Designating different areas in the vehicle. ٝ Always covering dirty product ٝ Only carrying either clean or dirty in the vehicle at one time. ٝ Another method that meets the standard. ■ Audit the personnel files of all personnel who repair/maintain equipment. Have they been properly trained? Have their skills been validated? If there is no documentation of these requirements, obtain it. ■ Develop a cleaning and equipment function check log (or other system/ process) to document proper cleaning and function checks of all equipment prior to client/patient use. Equipment repairs, disinfection, and function checks should be completed, at minimum, as required by the manufacturer. ■ Supplier Standard #27 requires suppliers to obtain oxygen from state- licensed supplier. Verify each year that your oxygen provider has a current state license and obtain evidence of the verification.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
Nerd Trailblazers (prepare the path for others)
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THE Accreditation Commission for Health Care
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
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