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
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?
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/medicareprovidersupenrollwww.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?
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 Supplies- Diabetic 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 Rehabilitation-Power 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- 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
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 – 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 NameDate: Item(s) received: 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 – 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 on- site 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 –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
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 PHYSICIAN ORDERS Patient Name: 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 CommodeOver the Bed Table BIPAPOxygen Concentrator with humidification CPAPPortable Suction Machine Feeding PumpSemi-electric Hospital Bed with surfaces as requested Hoyer LiftTrapeze Bar IV PoleWalker NebulizerWheelchair All related supplies 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:
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