Volume 2024 | No. 2
SURVEYOR
DMEPOS
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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