Volume 2025 | No. 2
SURVEYOR
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)
achc.org | (855) 937-2242 | 15
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