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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