Volume 2025 | No. 2
SURVEYOR
DMEPOS
SECTION 1: ORGANIZATION AND ADMINISTRATION DRX1-4A Frequency of the citation: 22%
Overview of the requirement: A designated individual is responsible for the organization’s programs and services and accountable to the governing body. In the absence of the manager/leader, another individual is authorized, in writing, to act as the manager/leader. Comment on deficiencies: Compliance is evaluated through review of personnel files, orientation records, and direct observation. Most deficiencies were cited because a temporary leader was not assigned and/or their duties are not defined in the applicable job description. Examples of ACHC Surveyor findings: ■ A temporary leader has not been appointed to act in the absence of the leader. ■ The duties of temporary leader are not included in the appropriate job description.
CLINICAL LABORATORY ACCREDITATION
Services
Distinctions
Home/Durable Medical Equipment Medical Supply Provider Complex Rehabilitation & Assistive Technology Supplier Fitter Community Retail with or without Fitter*
Clinical Respiratory Patient Management Custom Mobility
*This service is for licensed retail pharmacies that sell commonly used durable medical equipment and supplies. Community Retail Accreditation does not cover the provision of prescription medications or vaccines.
FREQUENT DEFICIENCIES FROM DMEPOS SURVEYS
Compliance tips for:
■ This standard requires documentation for: ٝ A designated manager/leader. ٝ A temporary leader.
Nerd Newbies (understand the requirement)
60%
■ A job description specifies the responsibilities of the manager/leader. ■ The temporary leader is authorized in writing to act in the absence of the manager/leader. The job description for this individual also specifies responsibilities applicable to the role.
50%
40%
■ Audit personnel files to confirm that:
Nerd Apprentices (audit for excellence)
ٝ Job descriptions are present for both the designated manager/leader and the temporary manager/leader. ٝ The job descriptions for these individuals address all applicable responsibilities. ■ Review policies annually to ensure a temporary leader is designated and that the designation is still accurate. ■ If there have been changes, modify the policy and or job description as needed.
30%
20%
10%
Nerd Trailblazers (prepare the path for others)
0% DRX1-4A DRX2-2A DRX2-4B DRX2-4C DRX4-7A DRX4-8A DRX5-1A DRX6-3C DRX7-4C DRX7-12D
Organization and Administration
Program/Service Operations
Human Resource Management
Provision of Care and Record Management
Risk Management: Infection and Safety Control
Quality Outcomes/ Performance Improvement
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