Concern ~ Focus ~ Purpose
Accreditation Readiness: Who's "Got Your Back"?

Geoffrey Krueger, BA, RRT, RCP
President 
Proactive Solutions HME Consulting LLC 



True story:

HME owner assigns accreditation preparation activities exclusively to one individual ("A") within the organization.



Individual "A" dies suddenly and unexpectedly.



Accreditation survey occurs.



Organization fails accreditation survey.



Organization goes out of business. 

Granted, this is an extreme situation, but the fact is, it actually happened.  In this case, the owner was not directly involved in the accreditation preparation process and individual "A" was the only person in the organization who knew much of anything about it.  Just for further clarification, this was a company that was up against the 09/30/2009 CMS deadline for DMEPOS accreditation for non-accredited providers, was already a Part B DMEPOS provider, and had a very significant percentage of their payor mix comprised of Medicare claims.  The end result was that the organization was unable to achieve accreditation by 09/30/2009, had their Part B DMEPOS billling privileges revoked, and was subsequently unable to sustain business operations and customer service due to cash flow problems.

There are a number of lessons that can be learned from this example, however, this article will focus on the one that seems to be most obvious, that is, the lack of sharing of information and implementation responsibilities in preparation for the accreditation site survey.  It certainly begs the question: "Who had "A's" back?"  The answer was, sadly, no one.   
  
SHARING WELL

There are many other similar real-life examples of situations in which the particular facts were somewhat different and the outcomes not quite so extreme, but that nonetheless, resulted in varying degrees of negative organizational consequences.  Time (and money) can be lost in the "re-doing" of things that could have been avoided if timely and  adequate sharing of information and implementation responsibilities had occurred.        
   
Information

To say that the accreditation preparation process has some detail involved in it would be an understatement.  The accreditation preparation process is chock-full of details.  Just the sheer amount of information alone can be daunting.





































Key points to keep in mind:

>> Don't treat the process as "Top Secret".  Involve everyone in the organization to some degree.
>> At least two individuals in the organization must be equally knowledgeable about ALL aspects of the process.
>> Organize the information in "bite-size" portions.
  
Implementation Responsibilities

Knowing what needs to be done with the information is the next step.  An organization may have the best written policies and procedures that have ever been conceived by the human mind, but it can also do poorly or even fail an accreditation survey if the company personnel are not knowledgeable with regard to those policies/procedures and there is little or no objective evidence that they have been implemented and are being  followed consistently.  Just as there is a learning curve involved in order to acquire the necessary knowledge about the accreditation process and standards, there is also an "action curve" that must occur in order to implement the standards.           

Key points to keep in mind:

>> Involve everyone in the organization to some degree.
>> Develop and follow timelines and benchmarks.
>> Conduct regular meetings and document plans and progress.  



PREPARING WELL

Having accomplished the education of company personnel and the implementation/documentation of the standards, policies, and procedures, there still remains one important element of preparation to address, i.e., document readiness for the site survey.  This is another way that you can "back-up" your efforts.  Having the necessary files, records, and other documentation well-organized and readily accessible will be very helpful on the day of survey.  If the "key" individual for accreditation is not present on the day of survey, then the 'back-up" individual(s) can step-in and facilitate the flow of the site survey process.  Regardless of who is or is not available on the day of the site survey, if the relevant documents are labeled and maintained in a manner that they can be easily located and identified, whoever is present will be able to find what they need.   The best practice in this regard would be to have manuals, binders, and folders that are relevant to the survey process physically centralized in the office (to the extent feasible/possible) in order to avoid searching for scattered files.  Clearly marking individual items (e.g., Policy/Procedure Manual, Performance Management, Staff Education, Minutes of Meetings, Contracts, etc.) will also be of great help.  Key staff members should be knowledgeable about where these materials are kept.

ORGANIZE AND LABEL DOCUMENTS

















ENSURE THAT THERE IS ALWAYS SOMEONE IN THE OFFICE WHO CAN LOCATE RELEVANT FILES

SLEEPING WELL

The owners/leaders of organizations that have incorporated some redundancy into the accreditation readiness process will be able to sleep better knowing that, no matter when the surveyor shows up:

1.  There are at least two individuals in the organization that have full and detailed knowledge of all aspects of the process
2.  All staff have been trained regarding the accreditation site survey and are prepared to answer questions, as applicable
3.  Relevant documentation is organized and readily identifiable and accessible



    
Organization
Administration
Service
Operations
Fiscal
Management
HR
Management
Records 
Management
Performance 
Improvement
Risk
Management

.Legal Authority 

Governing Body

Conflict of Interest

Leadership

Organizational Chart

Mission
Statement

Laws Regulations
Standards

Negative Outcomes


Services 
Description

Rights and Responsibilities

Supplier Standards

Abuse/Neglect

Complaints

Confidentiality and Security

Advance Care Directives

Emergency
 Response

Ethical Issues

Cultural Diversity

Communication
Barriers

Corporate
Compliance
 Program


Budget

Business Practices

Accounting

Financial Records Retention

Conveyance of Charges

Financial Hardship

Billing Procedures


Personnel Records

Personnel Management

Supervision

Orientation

Skills Competency

Continuing Staff Education

Contracted Services

Reference Library


Client Records

Assessment of Client Needs

Plan of
Care/Service

Client and
Caregiver
Education

Client Referral

Admission
Eligibility

Unmet Client
Needs

Client Transfer
and Discharge


PI Coordinator

PI Committee

Reporting
Responsibilities

Defining
Indicators

Frequency of Activities

Data 
Collection

Performance Thresholds

Plans of Correction


Infection
Control

Safety

Emergency/
Disaster 
Preparedness

Utilities
Management

Hazardous Materials

Incident Reporting

Product 
Handing/
Processing/
Tracking/
Storage/
Delivery

ACCREDITATION STANDARDS
Contact Us