Volume 2025 | No. 2
SURVEYOR
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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