Volume 2025 | No. 2
SURVEYOR
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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