Volume 2024 | No. 2
SURVEYOR
DMEPOS
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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