Volume 2025 | No. 2
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.
achc.org | (855) 937-2242 | 17
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