Volume 2024 | No. 2
SURVEYOR
DMEPOS
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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