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
achc.org | (855) 937-2242 | 5
4
Made with FlippingBook Annual report maker