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Volume 2025 | No. 2
Quality Review Edition THE Accreditation Resource for Data Nerds SURVEYOR
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
03 Corner View
04 From the Program Director
06 Frequent Deficiencies in Sleep
BOARD OF COMMISSIONERS
LEADERSHIP TEAM
Brock Slabach, MPH, FACHE Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CEO, MSMP ANESTHESIA SERVICES, LLC
Leonard S. Holman, Jr., RPh Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES
John Barrett, MBA Officer-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM
Matt Hughes VICE PRESIDENT, COMMUNITY CARE SERVICES Jonathan Kennedy, CPA, MBA VICE PRESIDENT, FINANCE AND CORPORATE SERVICES
Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO
Mark S. Defrancesco, MD, MBA, FACOG Secretary WOMEN’S HEALTH CONNECTI CUT/PHYSICIANS FOR WOMEN’S HEALTH (RETIRED)
Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
Jennifer Burch, PharmD OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS
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Volume 2025 | No. 2
SURVEYOR
CORNER VIEW WITH PRESIDENT & CEO, JOS É DOMINGOS
You made a great decision when choosing ACHC to accredit your sleep study program. Whether you are new or have years of experience with us, I am confident that you have already felt first-hand our intense focus on customer service. Real support that builds your team ACHC doesn’t engage in “accreditation theatre” through complex scoring rubrics or punitive surveys that give an illusion of rigor without adding any true value for your organization. Instead, we focus on real support designed to close any gaps between your current state and full standards compliance. We are known as Accreditation Nerds for our genuine belief in— and passion for—the efficacy of accreditation to enhance quality and safety in healthcare organizations. But we know it works best when those organizations understand and embrace continuous performance improvement. The Quality Review edition of Surveyor is an excellent place to start. This publication is a resource, demonstrating how ACHC program teams work to help you develop individual expertise within your organization, while recognizing that your staff may have varying levels of experience and current knowledge. The standards listed are the most frequently noted as non-compliant on recent surveys and the compliance tips provided are divided into categories to make them useful for individuals across a range of roles and expertise. “Accreditation Nerd Newbies” are just that: individuals new to the process of compliance with accreditation standards. ACHC uses a Plan- Do-Study-Act framework to organize standards. Even a “simple” standard may include multiple
elements for full compliance. Under Compliance tips for Nerd Newbies, we offer a clear summary of the expectations for each standard. “Accreditation Nerd Apprentices” understand the concepts of meeting and maintaining standards. Compliance tips for Nerd Apprentices focus on using data on hand to continuously assess how well your organization is performing. Finally, “Accreditation Nerd Trailblazers” are those individuals who are passionate about maximizing their organization’s capacity for excellence. They are enthusiasts who eagerly share their knowledge with colleagues to create a path forward. Nerd Trailblazers thrive on the goal of continuous improvement. Compliance tips for Nerd Trailblazers cover best practices designed to level up your organization. These tongue-in-cheek categories are our way of saying that it’s possible to approach accreditation seriously without being humorless. When we say that we want to help you develop your staff into a team of Accreditation Nerds, you immediately understand the goal. Partnership you can rely on Once a sleep center is ACHC-accredited, we become your partner, dedicated to meeting your needs. ACHC’s staff of Accreditation Nerds— account advisors, surveyors, clinical educators, quality and regulatory, and other experts— thrive on being helpful. Review the information on the pages that follow confident that we’re ready to dig in to answer questions, provide feedback, offer suggestions, and direct you to any additional resources you need.
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.
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Volume 2025 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
SLEEP
A survey with no findings—no identification of non-compliance—is exceedingly rare and that knowledge can be daunting. The important takeaway when exploring deficiency data is growth and improvement. This Quality Review edition of Surveyor identifies and analyzes the most challenging standards for Sleep Accreditation. This year’s data span initial and renewal surveys conducted between June 1, 2024, and May 31, 2025.
Documentation is critical The six standards identified in this report reflect non-compliance on more than 15% of the surveys performed. Although the standards highlighted in this report span four of the seven sections that categorize ACHC Standards, the reason for the deficiencies was consistent: Errors in documentation. Expected elements are either missing entirely, or incomplete. Think of your documentation as the story of the care you provide. Contracts describe responsibilities, policies and procedures describe what should happen and how, client/patient records tell whether the policies and procedures were adequately implemented. The most frequently cited standard is SLC5-1A , requiring a complete and accurate record for each individual sleep testing client/patient. The standard is specific to the policy and procedure that defines the required content. Each element of the record contributes to continuity of care by describing why the client/patient is seeking a sleep study, the state of their overall health, details of the testing performed, physician interpretation of the results, and more. The absence of any of the elements means a less complete picture upon which to build toward a satisfactory outcome.
Because sleep testing takes place in many different settings, some of the frequent deficiencies are specific to location. Returning again to SLC5-1A , home sleep testing has requirements that are not relevant to hospital- or other facility-based settings. Hospital sleep labs may want to give special focus to SLC2-4B and SLC4-2F . The first focuses on the expectation that clients/patients are provided with a means to make a complaint or express a grievance. The second, on background checks for staff providing direct patient care or with access to patient records. In both cases, relying exclusively on policies and processes at the organizational level may mean that these standards are non-compliant for the sleep lab as a distinct entity seeking independent accreditation. As always, your ACHC team is ready to help. I am new to the organization this year and eager to hear from our community about ways that we can be an even greater support to the quality care you provide.
SLEEP ACCREDITATION
Services
Sleep Lab/Sleep Center Services
Home Sleep Testing
FREQUENT DEFICIENCIES FROM SLEEP SURVEYS
60%
50%
40%
30%
20%
10%
Deborah Panza, BS, RRT, RPSGT Associate Program Director
0%
SLC2-4B
SLC4-2F
SLC4-9A
SLC5-1A
SLC6-1A
SLC6-1D
Program/Service Operations
Human Resource Management
Provision of Care and Record Management
Quality Outcomes/ Performance Improvement
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SLEEP
SECTION 2: PROGRAM/SERVICE OPERATIONS SLC2-4B Frequency of the citation: 18%
SECTION 4: HUMAN RESOURCE MANAGEMENT SLC4-2F Frequency of the citation: 17%
Overview of the requirement: At the time of admission, the sleep testing provider must inform each client/patient about how to contact its office, ACHC, and its state regulatory hotline with a grievance or complaint. Comment on deficiencies: Compliance is assessed through review of patient records and new client/patient packets. Most deficiencies noted one or more element of documentation was missing. Examples of ACHC Surveyor findings: ■ There was no evidence that written information provided to the client/patient included a contact at the sleep lab, the telephone number of the appropriate state regulatory body’s hotline telephone number(s), its hours of operations and the purpose of the hotline, and ACHC’s telephone number. ■ Contact information provided to new clients/patients does not include a phone number for ACHC. ■ Documentation provided to patients does not include information about the provider’s processes for receiving, investigating, and resolving complaints about care/services provided. ■ The hospital-based sleep lab’s registration process includes information about how to file a complaint/grievance but does not include any information specific to the sleep center nor does it identify the phone number for ACHC.
Overview of the requirement: For personnel providing direct client/patient care and those with access to client/patient records, evidence of a background check is required and maintained in individual personnel files. Comment on deficiencies: Compliance is assessed through review of policies and procedures and personnel files. Surveyors noted missing elements of required background checks. Examples of ACHC Surveyor findings: ■ Direct care personnel files did not have evidence of a National Sex Offender Public Website check.
■ Direct care personnel files did not have evidence of OIG exclusion list checks. ■ Written procedures regarding hiring a person convicted of a crime did not include: ٝ Documentation of special considerations. ٝ Restrictions. ٝ Additional supervision requirements.
Compliance tips for:
Compliance tips for:
■ The background check that is required for any individual who has direct client/patient care responsibilities or access to client/patient files includes three elements: ٝ A criminal background check. ٝ OIG exclusion list check. ٝ Sex offender registry check. ■ If the organization hires persons who have been convicted of a crime, policies must document: ٝ Special circumstances under which this may occur
■ The client/patient must be provided contact information for the purpose of reporting grievances/complaints to:
Nerd Newbies (understand the requirement)
Nerd Newbies (understand the requirement)
ٝ The sleep testing organization. ٝ The state complaint hotline. ٝ ACHC.
■ Written documentation of the contacts or written instructions for access to a website with complete contact information are acceptable as evidence of compliance. ■ Update admission information packets with any change in the sleep center’s process or staff responsibilities related to receipt of complaints/ grievances. ■ Check new admissions records monthly for inclusion of required documentation. ■ Lead onboarding and in-service training related to required client/patient record documentation.
Nerd Apprentices (audit for excellence)
ٝ Restrictions that may be placed on this hire. ٝ Additional supervision required for the hiree.
Nerd Trailblazers (prepare the path for others)
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Volume 2025 | No. 2
SURVEYOR
SLEEP
Compliance tips for:
■ Audit personnel files for complete documentation. ■ Correct errors as soon as they are found.
■ Personnel providing services on an hourly or per visit basis must have a written contract/agreement that specifies what and how services are to be provided, and details requirements to comply with the organization’s policies and procedures. ■ Contracts/agreements are time-limited to ensure review prior to renewal. ■ Professional liability insurance is required. ■ Audit files for inclusion of current contracts and insurance documentation.
Nerd Apprentices (audit for excellence)
Nerd Newbies (understand the requirement)
■ Review and revise policies and procedures as needed to include all required elements of the standard. ■ Develop checklists for required elements of personal files.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
SLC4-9A Frequency of the citation: 18%
■ Review contract/agreement templates to ensure that all required elements are captured. ■ Schedule contract review prior to expiration/renewal.
Nerd Trailblazers (prepare the path for others)
Overview of the requirement: The organization maintains written contracts/agreements that define the scope and expectations for services provided by outside personnel. Comment on deficiencies: Compliance is assessed through review of contract/agreement documentation and certificates of professional liability insurance. Deficiencies were cited for missing or expired evidence of insurance and for missing contracts with individuals providing services on behalf of the organization. Examples of ACHC Surveyor findings: ■ The organization had no evidence of professional liability insurance for any contract personnel providing direct care/service. ■ The organization does not have contracts in place for the medical director/interpreting physician who provide client/patient services on its behalf. ■ Contracts do not include a duration. ■ Professional liability insurance certificates for contract personnel providing direct care/service had expired.
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT SLC5-1A Frequency of the citation: 37% Overview of the requirement: Each service recipient has an individual record with documentation of all sleep testing in the home or the facility setting. Entries document receipt of the complete admission packet, and of all care/service provided including, at least: intake information, pre- and post-sleep questionnaires, technician notes during the study (facility-based only), type of device used (for HST), interpretation. Comment on deficiencies: Compliance is assessed through review of policies and procedures and client/patient records. Surveyors verify that patient records contain all required items detailed in the standard. Most deficiencies identified a specific item that was missing. For the period of this report, the most frequent omissions were pre- and post-sleep questionnaires, and the type of device used for HST. Examples of ACHC Surveyor findings: ■ Policies defining the required content of the client/patient record omitted emergency contacts, pre- and post-sleep questionnaires, scoring report, final report with physician interpretation. ■ Home sleep testing patient records lacked documentation of the type of device used for the study. ■ Client/patient records were missing pre- and post-testing questionnaires.
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SURVEYOR
SLEEP
■ The PI summary doesn’t document data collection related to complaints, adverse events, or client/ patient records. ■ The organization has not completed a semiannual (twice a year) PI summary in the past two years. ■ The PI summary did reflect ongoing monitoring of scoring reliability and consistency (including manual and computer assisted) between the sleep technicians (clinical personnel) and the medical director. Compliance tips for: Nerd Newbies (understand the requirement) The goal of the standard is for the organization to establish a meaningful Performance Improvement Program that uses data to evaluate the quality of its care, services, and operations. The required elements of the standard provide guidance on specific areas to use for data collection and measurement.
Compliance tips for:
One goal of this standard is to ensure continuity of care. Documentation of initial referrals, medications, Epworth score, testing methodology and device used, technician notes, and the patient’s response to treatment must be complete and traceable at a level of specificity that makes all relevant information accessible to the interpreting physician and to any subsequent provider.
Nerd Newbies (understand the requirement)
■ Audit for complete patient records.
Nerd Apprentices (audit for excellence)
ٝ Check for signatures, credentials, and dates associated with each entry.
■ When audits reveal missing documentation, continue to an analysis. ٝ Are errors specific to a particular required element? If so, create checklists. ٝ To individuals providing care/services? If so, plan focused training sessions. ٝ If your organization uses electronic records, ensure that credentials are automatically associated with electronic provider signatures.
Nerd Trailblazers (prepare the path for others)
■ Audit data collection activities to ensure that each required element is addressed. The intent of the semiannual report is to ensure that an analysis of the data is performed at least twice a year. ■ Build a checklist to support data collection and development of the semiannual PI report. ■ Review past PI reports to establish internal benchmarks. These become your metric to identify opportunities for improvement.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
SECTION 6: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT SLC6-1A Frequency of the citation: 20% Overview of the requirement: Each sleep lab must develop a Performance Improvement (PI) Program that measures, analyzes, and tracks quality indicators to assess its processes and outcomes. Comment on deficiencies: Compliance is assessed through review of policies and procedures, PI reports, and response to interviews. Deficiencies noted that required categories of data are omitted from semiannual summary reports. Examples of ACHC Surveyor findings: ■ The organization does not have a written PI Program. There is no description of the data collected by the organization for self-assessment. ■ The semiannual PI summary did not document data collections for: 1. Annual clinical competency of the personnel administering sleep testing 2. Monitoring the time frames from the study to the time the information is sent to the referring physician.
SLC6-1D Frequency of the citation: 18%
Overview of the requirement: This standard requires an annual PI report that describes the activities, findings, and corrective actions taken to achieve measurable improvement in the sleep services provided. Comment on deficiencies: The annual Performance Improvement Report is the source of evidence for compliance. Deficiencies were cited for failure to develop an annual report. Examples of ACHC Surveyor findings: ■ The PI annual report did not address the improvement activities and corrective actions taken. ■ There were no annual PI reports for the past three years.
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NOTES
Compliance tips for:
It’s not enough to collect data and analyze it for trends (as required by twice yearly summary described in SLC6-1A). The organization must then identify areas where it believes it can improve, set a goal for improvement, identify and implement a change/corrective action to achieve the goal, remeasure, and report on results. When the goal is achieved, the team must be trained so that the improvement is sustainable. When the goal is not achieved, another corrective action is expected. These activities are documented annually in a comprehensive PI report.
Nerd Newbies (understand the requirement)
■ Audit documentation of PI activities for:
Nerd Apprentices (audit for excellence)
ٝ A description of indicator(s) to be monitored/activities to be conducted. ٝ Frequency of activities. ٝ Designation of who is responsible for conducting the activities. ٝ Methods of data collection. ٝ Acceptable limits for findings or thresholds. ٝ Who will receive the reports.
ٝ Written plan of correction when thresholds are not met. ٝ Plans to re-evaluate if findings fail to meet acceptable limits. ٝ Any other activities required under state or federal laws or regulations. Note: These are the required elements for SLC6-2A but the PI annual report will not be complete without their inclusion. ■ Conduct staff training on the Performance Improvement Program to ensure engagement and investment.
Nerd Trailblazers (prepare the path for others)
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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THE Accreditation Commission for Health Care
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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