SURVEYOR Volume 2024 | No. 2 Quality Review Edition
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
BOARD OF COMMISSIONERS Brock Slabach, MPH, FACHE I Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CHIEF EXECUTIVE OFFICER, MSMP ANESTHESIA SERVICES, LLC Mark S. Defrancesco, MD, MBA, FACOG I Secretary PAST PRESIDENT, AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS Leonard S. Holman, Jr., RPh I Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT Roy G. Chew, PhD I Immediate Past Chair PAST PRESIDENT, KETTERING HEALTH NETWORK John Barrett, MBA I Board Member-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM Jennifer Burch, PharmD PHARMACIST/OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
03 CORNER VIEW
04 FROM THE PROGRAM DIRECTOR
05 FREQUENT DEFICIENCIES IN DMEPOS
LEADERSHIP TEAM
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES Matt Hughes VICE PRESIDENT, CORPORATE STRATEGY Barbara Sylvester, RN, BBA, MSOLQ DIRECTOR, REGULATORY AFFAIRS AND QUALITY
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Welcome to the 2024 Surveyor Quality Review. Each year, program-focused editions of this CORNER VIEW publication analyze compliance with ACHC standards over 12 months of surveys. This year’s data span initial and renewal surveys conducted between June 1, 2023, and May 31, 2024. ACHC-accredited organizations use the data to benchmark their performance by comparing these frequently-cited standards against their own survey report. There is value for non-accredited organizations, too. Because ACHC standards are closely aligned with CMS requirements, the information is relevant regardless of how your organization achieves its Medicare certification. For programs outside the Medicare regulations, the value remains. ACHC standards represent an important risk management/quality improvement framework. Reviewing the kinds of issues that arise in your peer organizations is an opportunity to act preemptively to manage your own risks. This is a critical business function in all healthcare settings. We know that some standards consistently present more compliance challenges than others. Frankly, if we offered only a list of frequent deficiencies, this publication wouldn’t vary much from year to year. Instead, Surveyor Quality Review gives insight into trends by quoting findings and offering practical tips to avoid citations. Some standards appear almost annually because of a large number of required elements. Perhaps a policy needs clarification, or staff members were not fully trained on a revision that impacts their work. Perhaps new or contract employees were not adequately oriented to a requirement for documentation, or employees made a change in their workspace that compromises fire safety. For a complex standard, any of these examples represents a potential deficiency and a risk to the organization, its staff, or its patients.
By sharing the observations of ACHC Surveyors, we offer an expert’s perspective on the most current issues impacting organizations. Trends by Program Internally, we use these data to guide the development of educational resources. Organizations seeking to renew their ACHC accreditation in 2024 were also surveyed in 2021. This year, our leaders are including comparative comments as they introduce their program findings. When we experience a large uptick in the number of initial surveys, as we have for several programs in this period, those difficult standards are likely to be prominent as new organizations confront them for the first time. However, we hope to see at least incremental improvement in standards that appeared as frequent deficiencies for this cohort of organizations three years ago. If we don’t see triennial improvements for some of the most frequently cited standards, it means we need to give more educational focus to these in the resources (webinars, workshops, tools) we offer. It is never ACHC’s intention to leave clients wondering about what is expected. To the contrary, our goal is to provide a range of resources that engage and enrich the experience of continuous quality improvement in the healthcare markets we serve. In this year’s first issue of Surveyor , I wrote about team collaboration and handoffs. Remember that ACHC serves as an extension of your team, ready to confer and coach. With Surveyor Quality Review , we are passing an evidence-based guidance tool to you. I hope you grasp it firmly and run with it!
MISSION STATEMENT
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
José Domingos President & CEO
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FROM THE PROGRAM DIRECTOR
DME businesses contribute to the healthcare continuum as a critical link between prescribers and patients, offering the equipment, supplies, and education patients need to achieve positive outcomes. This can mean providing high-tech, customized equipment to support mobility, equipment for oxygen therapy, crutches, or something in between. The key to a successful, sustainable business is the ability to achieve standards for quality and safety that meet patient needs and accurately document products and services delivered. Trending the Data In the 2021 Quality Review, 13 standards were cited on more than 20% surveys. Last year’s report noted six standards at that frequency. This year, only two standards are above the 20% threshold, indicating impressive advancement in overall compliance. ACHC-accredited suppliers should be proud of this achievement, as it demonstrates a clear commitment to continuous improvement and quality care. Within that inarguable success, there is one stumbling block. DRX7-12D remains as the most cited standard, and this year’s data reflect a significant uptick of deficiencies in 42% of DMEPOS surveys. Providing durable medical equipment and products often calls for a warehouse and/or delivery vehicle. Whether employing a subcontractor or in-house solutions, suppliers are responsible for ensuring proper cleaning, disinfection, storage, and transportation practices. DRX7-12D contains many specific requirements that are being missed. Staff training and checklists may help your organization avoid citations for items that are clearly identified as requirements of the standard. Regularly scheduled audits of personnel files would help in reducing noncompliance in many sections of this report. Personnel files contain position descriptions, documented trainings, evidence of competencies, and background checks – all missing elements that contributed to deficiencies. That said, both DRX4-7A and 4-8A reflect a drop in frequency from last year to this year, and this progress deserves kudos.
As you read through the report, we hope you find both guidance and comfort. Guidance if you recognize similar challenges at your organization, and/or comfort that you’re doing lots of things right. We’ve included a comprehensive list of surveyor comments and observations that illustrate the breadth and depth of potential pitfalls for suppliers both new and seasoned. Prior to annual education, consider assigning the topics among the employees and have them educate fellow staff members on their designated topic. This also helps the employees to become more familiar with the policy manual. A New Chapter As you may know, my tenure as the Program Director of the DMEPOS Program is drawing to a close. The DME landscape has grown and changed over the years, but one thing has remained constant – my belief in the power of accreditation. To put it simply, accreditation makes your organization better. If your organization is better, other organizations will follow suit and before you know it, the entire industry has improved. ACHC continues to evolve and ensure that the cycle continues. It has been my honor to assist organizations from single owner start-ups to corporate entities with hundreds of locations over the past 18 years. While I fully intend to enjoy my retirement, you may still see me from time to time. As always, please don’t hesitate to reach out to your Account Advisor with questions.
DMEPOS ACCREDITATION
Services
Distinctions
Home/Durable Medical Equipment Medical Supply Provider Complex Rehabilitation & Assistive Technology Supplier Fitter Community Retail Community Retail with Diabetic Shoes
Clinical Respiratory Patient Management Custom Mobility
FREQUENT DEFICIENCIES FROM DMEPOS SURVEYS
60%
50%
40%
30%
Tim Safley, MBA, RRT, RCP Program Director
20%
10%
0%
DRX1-4A
DRX4-2H
DRX4-2J
DRX4-7A
DRX4-8A
DRX5-1A
DRX7-5B
DRX7-12D
Organization and Administration
Human Resource Management
Provision of Care and Record Management
Risk Management: Infection and Safety Control
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Examples of surveyor findings:
n Written procedures do not indicate that background checks are required. n Files of direct care personnel and personnel with access to client/patient records did not have evidence of criminal background checks, OIG exclusion list checks, and/or National Sex Offender registry checks. n Personnel files did not have evidence of background checks per state licensure regulations. n Obtain required background checks for all direct care providers and employees that have access to patient information. Document completion in personnel files. n Use an employee docum entation checklist annually to ensure employee files include required background checks.
SECTION 1: ORGANIZATION AND ADMINISTRATION DRX1-4A 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. Compliance is evaluated through review of personnel files, orientation records, and direct observation. Most deficiencies were cited because a temporary leader was not appointed and/or documented via job description. In other cases, written procedures did not adequately describe the responsibilities of the designated leader.
Tips for compliance:
Comment on deficiencies:
Maintain awareness of state licensure requirements by monitoring websites and signing up for e-newsletters.
Frequency of citation:
22%
Examples of surveyor findings:
n A temporary leader has not been appointed to act in the absence of the leader. n The duties of temporary leader are not included in the appropriate job description. n Written procedures do not outline the responsibilities and authority of the individual designated as leader. n Update written procedures to include the responsibilities and authority of the individual designated as leader. n Designate an individual to act as the temporary leader. n Clarify the job description and the level of authority for the temporary leader. Include duties such as employee hiring and firing, authorizing payroll, signing checks, authorizing purchases, access to bank accounts, etc.
DRX4-2J Overview of the requirement:
Individual annual performance evaluations are conducted for all personnel and are completed, shared, reviewed, and signed by the supervisor. Compliance is evaluated through review of policies, procedures, personnel files, and interviews. Most deficiencies were cited because the performance evaluation was not performed and/or properly documented.
Comment on deficiencies:
Tips for complianc e:
Frequency of citation:
14%
Examples of surveyor findings:
n Personnel files did not contain evidence of a performance evaluation conducted at least once every 12 months. n A recent annual performance evaluation did not contain a supervisor signature. n Complete performance evaluations for personnel that do not have them and repeat for all personnel at least once every 12 months. n Complete an annual audit of personnel records and verify the presence of performance evaluation documentation. n If performance reviews are completed verbally, document the completion with signature acknowledgment by all parties participating.
Tips for compliance:
SECTION 4: HUMAN RESOURCE MANAGEMENT DRX4-2H
Overview of the requirement:
Personnel with direct care responsibilities or access to patient records undergo an initial background check including the OIG exclusion list, a criminal background check, and the national sex offender registry. Compliance is evaluated through review of policies, procedures, and personnel files. Personnel files often contained partial documentation but were missing at least one of the required components.
Comment on deficiencies:
Frequency of citation:
14%
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DRX4-8A Overview of the requirement:
A written annual education plan is established for each classification of personnel. Ongoing in-services and trainings include a variety of methods and resources that provide current, relevant information that covers, at minimum, nine topic areas defined by the standard. Compliance with the standard is assessed through review of policy and procedures, response to interviews, and review of training/in-service logs. Most deficiencies noted that some or all the required topics were missing from an education plan. Staff interviews did not demonstrate knowledge of the requirement. Note: The education plan covers topics required for all staff. Standard DRX4-7A (above) addresses additional training related to competencies required for specific roles and equipment.
Comment on deficiencies:
DRX4-7A Overview of the requirement:
The organization must implement a Competency Assessment Program that mandates participation from all personnel who set up, train, clean, test, repair, or educate on the use of medications, equipment, and/or supplies. Compliance is evaluated through review of policies and procedures and documentation of ongoing competency assessment. Most deficiencies resulted from missing documentation in personnel files. Policies and procedures were also missing key elements of the requirement.
Frequency of citation:
19%
Examples of surveyor findings:
n The organization’s education plan did not include: Emergency/disaster training. Workplace (OSHA) and client/patient safety techniques. Client/patient rights and responsibilities. Cultural diversity. ٝ Personnel files did not include evidence of completion of required annual training. n Upon interview, personnel could not describe the ongoing education provided by the organization. n Complete and document completion of annual training for all personnel. Use a sign-in sheet that clearly records attendance for all applicable staff. n Create an ongoing education plan that includes all topics required by the standard. n Documentation of “annual policy review” does not automatically replace the requirement for annual education on cultural diversity, patient rights, and patient complaints. Prior to annual education, assign the topics among the employees and have them educate fellow staff members on their designated topic. This also helps the employees to become more familiar with the policy manual.
Comment on deficiencies:
Frequency of citation:
16%
Examples of surveyor findings:
n Personnel files did not contain documentation of competency assessments for personnel who set up, train, and/or educate the use of medications, equipment and/or supplies. n The policy does not describe who is required to have a competency assessment and in what time frames. n The organization provides a comprehensive Competency Assessment Program for new staff. They also provide ongoing competencies when a new product or service is introduced. However, the organization does not currently document an annual competency assessment. n Add to written procedures how you will assess the competency of personnel who set up, train, and/or demonstrate the use of equipment and/or supplies and the required time frames for assessments. n Perform annual audits to confirm HR records contain documentation of competency assessments. n Product/equipment specific competency assessments must be performed by observation with a checklist or by passing a product/equipment specific exam. To assess competency of employees in the company that only have 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.
Tips for compliance:
Tips for compliance:
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SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT DRX5-1A Overview of the requirement: Each client/patient has an accurate, complete record that includes all required items. Comment on deficiencies:
QUALITY OUTCOMES/ PERFORMANCE IMPROVEMENT
Section 6 of the DMEPOS standards is dedicated to Quality Outcomes/Performance Improvement. Performance improvement (PI) activities have improved greatly across organizations, and the deficiencies did not meet the threshold for inclusion in this report. However, PI is an important part of your organization’s success. That’s why surveyors often suggest using PI as a method to ensure compliance in every section of the standards. Missing an element of documentation? Not sure why you have repeat deficiencies? Audit, track, and analyze! Use PI to your advantage. We encourage all suppliers to treat every finding as an opportunity to improve. Here are some surveyor suggestions for using PI indicators to address common deficiencies in other areas of the survey: n Perform a mock recall audit on lot numbers. Monitor via your PI program. n Conduct periodic auditing for missing items as part of your client record review PI activity (e.g., standing orders signed by physicians). n Routinely monitor expiration dates and remove expired product from patient-ready areas. Use this as a PI indicator. n Monitor the corrective actions from your ACHC plan of correction as part of your PI program to ensure they were effective. n Keep a record of equipment breakdowns/malfunctions and look for trends as part of the PI program.
Compliance with the standard is assessed through review of policies and procedures and patient records. Deficiencies resulted from the lack of initial and/or home assessments, inconsistencies with physician orders, and the omission of an emergency contact.
Frequency of citation:
17%
Examples of surveyor findings:
n Records did not contain evidence of a home assessment conducted by the delivery driver. n Records did not contain an emergency contact because the patient refused, but the reason was not documented. n Patient record contained physician orders for a standard wheelchair; patient received a lightweight wheelchair. n Patient file did not have the serial number for the nebulizer, and there was no follow up to obtain the serial number. n Records lacked an initial assessment. n Records for mastectomy and brace patient files were missing a valid prescription. n Complete and document initial and home assessments for all new clients/ patients admitted for service. n Create a process for team members to document when the patient opts to not provide an emergency contact.
Tips for compliance:
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SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL DRX7-5B Overview of the requirement: The organization has a fire safety plan and emergency power system. Comment on deficiencies: Evidence of compliance includes review of policies and procedures and direct observation. Surveyors frequently noted a failure to conduct annual fire drills or inspect fire extinguishers.
DRX7-12D Overview of the requirement:
Equipment used in the provision of care/service must be cleaned, stored, transported, delivered, and set up according to the organization’s policies and procedures. Evidence of compliance includes direct observation, interviews, and personnel file review. Most deficiencies were related to improper equipment storage and cleaning procedures in warehouses and delivery vehicles.
Comment on deficiencies:
Frequency of citation:
42%
Frequency of citation:
21%
Examples of surveyor findings:
n Improper storage practices: Company does not have a method of tracking of products with lot and/or serial numbers for manufacturer recalls. Expired suction catheters were found in areas housing patient-ready product. Inoperable equipment and batteries to be disposed of were not properly segregated. Several oxygen cylinders of varying sizes were observed standing upright with no method utilized to secure them and prevent them from falling over. Oxygen cylinders were full but were stored in the designated empty 02 cylinder storage area. n Insufficient cleaning/disinfection practices: Clean and ready oxygen regulators were not protected from dust/dirt on delivery vehicles and in the warehouse. Upon interview, a warehouse staff member could not describe the process for cleaning returned equipment, specifically how long the chemical disinfectant used to clean/disinfect equipment was to remain “wet” on the equipment. The disinfectant being used (Lysol wipes, bedding license solution) is not effective against all infectious pathogens. Returned dirty CPAP equipment is processed, cleaned and tested on the same surface and in the same area as patients are instructed and setup with new CPAP equipment. n Delivery vehicle maintenance/documentation: The delivery vehicle was missing a valid vehicle registration. Delivery van front windshield glass is fractured and needs replacement. SDS sheets or access to SDS information wase not found in the delivery vehicle(s) and no eye wash was present.
Examples of surveyor findings:
n There was no evidence of any smoke detectors in the facility. n Annual fire drills and emergency power drills have not been completed. n Front exit light, rear exit light, rear warehouse exit light, and front warehouse exit light were all defective, and not illuminated on test button per fire code. n There was no evidence that fire extinguishers in the delivery vehicle received annual maintenance. n Facility inspections are done monthly but not documented in accordance with company’s process. n Test emergency power sources and items with a battery backup such as exit lights, smoke detectors, server batteries, etc., on an annual basis. n Ensure that fire extinguishers are maintained on an annual basis, and that there is documentation that it was completed. n Post evacuation diagrams into all back rooms and areas where exit signs are not visible.
Tips for compliance:
Document employee participation in the fire safety plan by implementing an attendance log.
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NOTES
Tips for compliance:
n Improper storage practices: Identify a clean and dirty area for rental equipment as well as an area to store quarantined/expired product. Retrain all staff that handle oxygen and/or educate patients about oxygen safety about the safe use and storage of oxygen cylinders and oxygen related equipment. Use communication tags such as “broken, do not use” to provide clear communication to all staff of medical equipment in quarantine area pending parts / repair. n Insufficient cleaning/disinfection practices: Stay timely with equipment servicing and repair to avoid creating issues with warehouse cleanliness and segregation of equipment. Utilize a cleaning and equipment function check log to document proper cleaning and function checks of all equipment prior to patient use. Create a regular dusting schedule to ensure continued cleanliness of supplies and equipment stored in the warehouse. Obtain and use hospital-grade disinfectant effective against all pathogens. Look for hydrocarbon/alcohol free disinfecting solutions for cleaning/disinfecting any oxygen equipment or cylinders. Educate personnel on the manufacturer’s designated amount of time disinfectant is to remain wet on equipment to be effective. n Delivery vehicle maintenance/documentation: Comply with all applicable vehicle laws and regulations; inspect delivery vehicles on a regular basis. Place SDS sheets in delivery vehicles. Educate on SDS availability via cell phone.
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
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NOTES
NOTES
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ACHC Redefining the Culture of Accreditation
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
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SURVEYOR 2024, NO. 2
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