Volume 2025 | No. 2
SURVEYOR
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)
achc.org | (855) 937-2242 | 7
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