Volume 2025 | No. 2
SURVEYOR
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)
achc.org | (855) 937-2242 | 19
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