You ARE Smarter Than A
Fifth Grader!
You CAN Successfully Pass
Your Accreditation Survey
Mary Ellen Conway
President
Objectives
• Review overall accreditation guidelines
regardless of who you choose as your
accreditor
• Understand the importance of adequate
preparation
• Learn the most common pitfalls that
present difficulty for suppliers and how to
prevent them
• Review the survey process
Objectives
Have fun and win
fabulous prizes!
Handouts
Can be found at:
MedTrade Website
and
www.capitalhealthcaregroup.com
History
History
In 2003 the Medicare Modernization Act
legislated that all DMEPOS providers
would need to become accredited in order
to receive reimbursement for identified
products from CMS
Question:
In what year did MMA ’03 require that all
providers become accredited?
Answer
2007!
History
The industry argued that there were different accreditors
with differing requirements, so CMS would need to issue
their required Quality Standards. The first attempt at this
was a 104 page documents rife with ludicrous
requirements.
After receiving 5400 comments, CMS issued a revised
14 page document, the “Final Quality Standards” in
August of 2006.
In December of 2006, CMS identified 10 (first it was 11,
but two merged) “Deemed Status” accrediting
organizations whose programs were determined to meet
the Final Quality Standards from which suppliers could
choose from to become accredited.
History
CMS released the most recent updates to
the Final Quality Standards this month.
They are posted at:
www.cms.hhs.gov/medicareprovidersupenroll/
Left side of the page in the column:
DMEPOS Accreditation
The Recognized Accreditors
JCAHO
CHAP
HQAA
ACHC
NABP
The Compliance Team
NB of A for Orthotic Suppliers
ABC of O&P
BOC
CARF
History
Question:
Each of the 10 approved Accrediting
Organizations is applicable for your needs,
so it doesn’t matter which provider you
choose to accredit you.
TRUE or FALSE?
Answer
FALSE
Comparing “Apples-to-Apples”
Product Category Definitions
DME Limited
Mobility Aids: Manual W/C, Cane, Walker, Crutches,
Stationary Commode Chairs, Wound Care and Ostomy Supplies
Urological Supplies: Bedpans, Urinals
DME includes Limited and- Manual and Electric Beds, Traction Equipment
Medical SuppliesDiabetic Supplies, Enteral Products (Non-home visit items)
Respiratory-
Home medical equipment and supplies covered include respiratory
equipment and supplies, oxygen, concentrators, reservoirs,
conserving devices, cylinders and oxygen accessories and supplies,
home invasive mechanical ventilators, respiratory assist devices,
continuous and intermittent positive pressure breathing devices,
nebulizers
RehabilitationPower Mobility devices including complex Rehab and Assistive
Technology
Orthotics and Prosthetics- Custom fabricated, custom fitted, custom-made orthotics, prosthetic
devices, somatic, ocular and facial prosthetics, therapeutic shoes, braces
and artificial limbs
Accreditation Commission for
Healthcare (ACHC)
www.achc.org
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Rehabilitation
Orthotics and Prosthetics
American Board of Certification for
Orthotics and Prosthetics (ABC of
O&P)
www.abcop.org
Orthotics and Prosthetics
DME Limited- Wound Care/Incontinence,
Mobility Aids only if in conjunction with
O&P
Merged with the Board for Certification in
Pedorthics (www.cpeds.org)
Board of Certification of
Orthotics and Prosthetics (BOC)
www.bocusa.org
Orthotics and Prosthetics
DME
Medical Supplies
Commission on Accreditation of
Rehabilitation Facilities (CARF)
www.carf.org
Rehabilitation
Orthotics and Prosthetics
Community Health Accreditation
Program (CHAP)
www.chapinc.org
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Rehabilitation
Orthotics and Prosthetics
The Compliance Team
www.exemplaryprovider.com
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Rehabilitation
Orthotics and Prosthetics
Healthcare Quality Association
on Accreditation (HQAA)
www.hqaa.org
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Rehabilitation
Orthotics and Prosthetics
Joint Commission (JCAHO)
www.jcaho.org
DME- All Equipment
Medical Suppliers (Pharmacies)
Respiratory
Rehabilitation
Orthotics and Prosthetics
National Association of Boards
of Pharmacy (NABP)
www.nabp.net
DME Limited- Wound Care/Incontinence,
Mobility Aids
Medical Suppliers (Pharmacies)
National Board of Accreditation
for Orthotic Suppliers (NBAOS)
www.nbaos.org
Orthotics and Prosthetics
Tips to Use in Choosing Your
Accreditor
• CMS is not your only payer! (How about hospice???)
– Payer or state licensure requirements to be accredited ex:
Anthem BC, State of Florida, Oklahoma Medicaid
• What is the accreditor’s schedule and what are the requirements
for in-between?
– ex: Triennial and or annual updates
• Fees paid vs. administrative costs
• Other services (infusion, home health)
• Process (electronic vs. paper)
• Interview/discussions with accrediting organization—your
perceptions--- Who’s downstairs in Accreditation Central?
• Your peer’s experience
HISTORY
Of the 10 accrediting organizations, The
Joint Commission (JCAHO-JAYCO) has -been accrediting organizations for the
longest time
Question:
TRUE or FALSE?
Answer
FALSE
CHAP was the first to accredit DME in 1965
JCAHO began to accredit DME in 1988
Science
Science- Infection Control
Infection Control in one of the “pillars” of
accreditation. Ensuring that you are not
making your staff or your
customers/patients sick by transmitting
infection is paramount in the process of
selling/renting items and in the services
you provide
Science- Infection Control/Safety
Enforce the use Personal Protective
Equipment (PPE) with your staff
Question:
What is the goal of PPE? Can you name
all of the types of items included in PPE?
Infection Control and Surveillance
• Manner in which items
are cleaned, serviced,
stored (clean – dirty)-logs
• Decontamination, OSHA issues,
safety equipment and training
• Reporting of infections: patient or staff
• Personal protective equipment
• Visits/patient contact- handwashing
• Retail- customer rest rooms
Science- Infection Control/Safety
Question:
The Final Quality Standards require that
you monitor patient and staff infections
TRUE or FALSE?
Answer
TRUE
The recently updated Final Quality
Standards include the tracking of patient
and staff infections
Science- Infection Control/Safety
The accrediting organizations have infection
control standards that list requirements for the
Infection Control / Bloodborne Pathogens and
Safety education that you offer to your staff and
contractors
Question:
Employers have to offer Hepatitis A and B
Vaccines to all of their employees
TRUE or FALSE?
Answer
FALSE
OSHA requires that employers make a risk
assessment to determine whether or not their
staff members are at an increased risk for
contraction of Hepatitis B, and then offer the
staff members affected the vaccination (a series
of 3 injections over 6 months) at the employer’s
expense. Staff can accept or decline the vaccine
and this must be documented
What Problems with Infection
Control/Safety Issues are at YOUR
Organization?
• Infection Control:
– Clean vs. Dirty- Warehouse, trucks
– Handwashing, Alcohol Gel
•
•
•
•
•
•
Chemicals scattered throughout
Labeling/placarding of facility/vehicles
Fire drills not conducted annually
Fire extinguishers not current
Stacks of forms/trash
Trucks not clean, up to date on maintenance
Geography
Geography – Home Visits
Surveyors will interview patients, either in
the home, at the counter, over the phone
asking how they were oriented, how to
reach the office, how the services has
been, any problems…
Geography – Home Visits
Get out there and see what’s happening with
your customers, observe interactions in
your retail locations, LONG BEFORE your
surveyor finds problems:
Make sure your staff have complete files
Check that the materials you provide to
customers are documented:
USE A CHECKLIST
Main Reasons Organization Fail
Teaching and instruction is
required by Medicare when you
sell or rent and item
→ Make sure your staff is providing
complete teaching and instruction
including education on all safety
and potential hazards
Checklist of Paperwork Provided
Customer Name
Item(s) received:
Date:
I have received the following information:
Company Information/Hours of Operation
Welcome
Rights and Responsibilities
Patient Information / Complaint Procedure
Emergency Preparedness / Consent for Third Party Review
Home Safety Information
HIPAA Notification
Educational and Instructional Materials
Financial Responsibility (signed copy stays in file)
For Medicare Customers Only:
21 Supplier Standards
Assignment of Benefits
Medicare Authorization (signed copy retained in file)
Items not provided to all- checked when provided and signed copy retained in file:
 Warranty Information
 ABN (only provided when indicated)
 Inexpensive or Routinely Purchased Item
Customer Signature
Date:
Retain Above Portion in File
Separate Here ---------------------------------------------------------------------------------------------------------------------------------------- Separate Here
I have received the following information:
Company Information/Hours of Operation
Welcome
Rights and Responsibilities
Patient Information / Complaint Procedure
Emergency Preparedness / Consent for Third Party Review
Home Safety Information
HIPAA Notification
Educational and Instructional Materials
Financial Responsibility (signed copy stays in file)
For Medicare Customers Only:
21 Supplier Standards
Assignment of Benefits
Medicare Authorization (signed copy retained in file)
Signed copies retained in file:
 Inexpensive and Routinely Purchased Item
 Warranty Information
 ABN
Customer Copy
Math
Math – Performance Management
Performance Management is one of the
main areas suppliers have difficulty with as
they start the accreditation process
The accreditors vary in their standards for
Performance Improvement, but all require
that you comply with the requirements in
the Final Quality Standards
CMS Requirements
Performance Management
Implement performance management
plan that measures outcomes of
customer service, billing practices and
adverse events. At a minimum,
measure:
– Beneficiary satisfaction and complaints
– Timeliness of response to questions, problems and
concerns
– Impact of business practices on adequacy of
beneficiary access to items, services, information
– Frequency of billing/coding errors
– Adverse events due to malfunctioning
equipment/item (signs and symptoms of infections)
Performance Management
1. Beneficiary satisfaction surveys
2. Patient complaint log
3. After hours (on call) log to prove
timeliness of response to questions,
problems and concerns
4. Log that documents frequency of
billing and/or coding errors
5. Log documenting adverse events
(as defined by your P & P manual)
6. Log of infections (patients and staff)
Math – Performance Management
Most accreditors require that you have
implemented your Performance Management
Program prior to survey. Some require anywhere
from 60 days to 3 months of data collected with
plans for improvement identified
Question:
If this is required and you don’t have it in place for
survey, you will always have to be re-surveyed
TRUE or FALSE ?
Answer
FALSE
It depends on the deficiency found and the
accreditor’s standards. Some AO’s require
up to 3 months of data collected prior to
survey, some have waived the
requirement. Some allow you to send this
data into the organization as a follow-up,
others will require another follow-up onsite survey.
Other Items to Remember
Human Resources:
• Documentation of Competency
• Job Descriptions
• Annual/Bi-annual Performance Evaluations
• Equipment Management
Documentation of Preventive Maintenance
• Clean/Organized Repair Area
• Adequate Resource Manuals
Personnel Files
• Personnel File for Each Staff Member
–
–
–
–
–
–
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Date of Hire
Evidence of Interview
Background checks
Driver’s License/Driving Record
Signed Job Description and Annual Evals
Signed Orientation Checklist
Competency Evals- on hire and annually
• See the specific requirements for the
accreditation program you choose
Common Deficits
• HR Charts
– Incomplete
– Annual Evaluations not done
– Incomplete Hep B documentation
– Medical/Health Info not separated
• Patient Charts
– Incomplete documentation of receipt of
paperwork
– Forms not witnessed, dated, completed as
indicated
Main Reasons Organization Fail
• Lack of Preparedness
• Few Staff Aware of
Process/Requirements/PI
• Lack of Focus and Follow-through
• Main items:
– Physician Orders
Problems
• Oxygen
• CPAP
• Hospice
CMN is not an O2 order unless
• Text in the bottom box
is completed:
– 2L/minute via NC cont
CPAP
• Must have a copy of
the sleep study in the
file
P.O. Box 346
Beattyville, KY 41311
Phone (606) 464-9100 Fax (606) 464-9191
Patient Name:
PHYSICIAN ORDERS
Start of Service Date
Please provide the above named patient of Hospice Care Plus with any or all of the following items as needed:
Bedside Commode
BIPAP
CPAP
Feeding Pump
Hoyer Lift
IV Pole
Nebulizer
All related supplies
Over the Bed Table
Oxygen Concentrator with humidification
Portable Suction Machine
Semi-electric Hospital Bed with surfaces as requested
Trapeze Bar
Walker
Wheelchair
For transport outside the home:
Pre-filled oxygen tanks,
Oxygen conserving device if needed
Oxygen is ordered up to 5 L/min via nasal cannula as needed for comfort
If indicated by weight, provide equipment sized for bariatric use.
Other Equipment or Additional Orders:
Physician:
Signature:
Date:
All Videos
• Available from VGM see them at Booth #
– Accreditation for HME
– Infection Control for HME
– Many more titles available
Any Other Questions?…
Congratulations
to all of our
fabulous prize
winners!
Thank You!
Mary Ellen Conway
President
Capital Healthcare Group, LLC
Bethesda, MD
301-896-0193
www.capitalhealthcaregroup.com