Mythbusters! Accreditation Myths and Legends

1. Mythbusters! Accreditation Myths and Legends MedTrade Wednesday, October 3, 2007 Mary Ellen Conway, President Capital Healthcare Group

2. Accreditation Myths and Legends Learning Objectives: • What is the format of a survey? • How can you prepare? • What is reality and what is a myth? • The top 10 problems found and how you can avoid them

3. Where Do We Begin? • What is the typical format of the survey? • Now all are unannounced • Formats • JCAHO Tracer Methodology • Review of Patient Lists, Personnel Lists, Patients Scheduled for Visits

4. Two-Day Survey Day One Entrance Conference Interview of Leadership Review of Survey Schedule Review of Patient Census Selection of Patients to Visit (Close to the Office) Review of Patient Charts (Include those being visiting) Selection of Employee Charts (or Tracers to Determine) Patient Visits and/or Chart Review End of Day Wrap up and Plan for Tomorrow May take Policy/Procedure Manuals, PI Program info to review overnight

5. More on a Two-Day Survey Day Two Review of Day One or items reviewed overnight Continue Patient Chart, Personnel Chart review Continue Visits, Staff Meetings Telephone Interviews Can Include Referral Sources, Discharged Patients Review PI program Review minutes of Board Meetings, planning sessions, staff meetings Exit Conference Required to mention all recommendations/concerns

6. Main Reasons Organization Fail • Lack of Preparedness • Few Staff Aware of Process/Requirements • Lack of Focus and Follow-through • Main items: • Physician Orders • Infection Control • Incomplete HR Files

7. Before We Begin • Ensure that you have worked through your accreditor’s standards • Make sure your policies and procedures are aligned with the accreditation company’s standards • You have completed all requirements

8. CMS Final Quality Standards • Were released on 8-14-06 • 14 pages—as compared to 104 • Found on the CMS website at: (http://www.)cms.hhs.gov/CompetitiveAcqforDMEPOS/04_New_Quality_Standards.asp • Compliance with these standards is enforced through the accreditation provider you select

9. #10 Psychotic Surveyors Myth or Reality?

11. Fact: You are the accreditor’s customer You have ways to appeal You need to be prepared! Is it Myth or Reality?

12. In Preparation, Create Your Checklist • Develop your own or purchase one • Check to make sure you have everything you need on your list • Review your standards/guidelines • Make sure each aspect of your services and ALL types of services you provide are addressed (retail, delivery, on-line?)

13. Creating Your Checklist • Warehouse/layout • Educational Calendar • Staff and Patient Interviews • Infection Control and Surveillance • Performance Improvement/QI • Personnel Files • Patient Records • HIPAA • Home Visits

14. Keep in mind any other compliance that might be assessed, such as HIPAA Review your entire operation for HIPAA compliance especially: • Customer areas • Staff areas • Security of files, billing, patient records, delivery logs, items patients sign • Shredding? • Process for sending patient information and receiving referrals and orders • Example: What’s at your fax machine? Cover Sheet Text?

15. #9 Everyone Doesn’t Need to Know This Stuff Myth or Reality?

17. Fact: Everyone needs to know what’s going on You can not do things in a vacuum Everyone needs to be prepared! Is it Myth or Reality?

18. #8 PI, QI What’s the Difference? It’s all over my head and I don’t know anything about it! Myth or Reality?

19. P.I./Q.I ProgramsPerformance or Quality Improvement • Usually the one area that organizations have not had in place prior to the pursuit of accreditation • Can be done internally without outside assistance---but may require benchmarking • Focuses on item/area that can be monitored and improved (Customer Satisfaction)

20. P.I./Q.I Programs • Are Written • Show involvement of staff (as many as appropriate) • Program is presented, approved and reported on quarterly • Generally need to show at least 3 months of data when you submit your application. • Data should be collected, analyzed and acted upon (all of this is written in the PI Report)

21. Second Quarter Washington, Division FY 2006

22. Overall Mean Agency

24. Performance Management • Beneficiary satisfaction surveys • Patient complaint log • After hours (on call) log to prove timeliness of response to questions, problems and concerns • Log that documents frequency of billing and/or coding errors • Log documenting adverse events (as defined by your P & P manual) Most accrediting organizations require at least three months of surveys collected and summarized with plans for improvement or you will have to provide written follow-up and possible a re-visit

25. #7 No Ride Alongs? Tell them your insurance carrier prohibits it!

26. Fact: There is no insurance issue If questions are not asked during the ride, they will be asked at other times Practice interviews, safety issues Examples Reality

27. #6 Inventory Management I do it all in my head!

29. Final Supplier Quality Standards 2 Sections First Section: Business Services • Administration • Financial Management • Human Resource Management • Consumer Services • Performance Management • Product Safety • Information Management

30. CMS Final Quality Standards Financial Management 1. Implement financial management practices that ensure accurate accounting and billing. 2. Accurate, complete and current financial records 3. Cash or accrual based accounting 4. Link equipment to client 5. Manage revenues and expenses on an ongoing basis: • Reconcile charges with invoices, receipts and deposits • Operating budget • Mechanism to track actual revenues and expenses

31. CMS Final Quality Standards Product Safety Equipment management program that promotes the safe use of equipment and minimizes safety risks and hazards including: • Plan for identifying, monitoring and reporting failures, repair and preventive maintenance • Investigate any accident or injury (within 72 hours or 24 hours if results in hospitalization or death) • Contingency plan for response to emergencies and disasters

32. Must Comply With: CMS Final Quality Standards Your Accreditor’s Requirements Requirements

33. #5 “Red Tape” on the Floor Myth or Reality?

34. It’s an UrbanLegend! You are held accountable for following your own Policies and Procedures Is it Myth or Reality?

35. #4 Preventive Maintenance What Do I Need to Have Available?

36. Fact: You need to be able to explain your program for Preventive Maintenance on appropriate items How to identify items in the field that need it How to show that it’s been performed appropriately and timely Reality

37. # 3 Policies and Procedures A “MUST HAVE” in order to become accredited

38. My P&P List- Policies you need to review • Policy and Procedure Manual—At a Minimum: • Patient Admission, Transfer, Discharge • Compliance with all Local/State Requirements • Supporting evidence attached • Handling of Equipment • Storage of Equipment • Inventory Control and Management • OSHA and Infection Control • Performance Improvement (P.I.) and Data Collection ***Review the requirements of the company you select**

39. More of My List • Employment and Personnel Policies • Include Written Job Descriptions and Org Chart • Competency Assessment Program • Sample Contracts-if you use them • Personnel File for Each Staff Member • Files organized and kept in locked, secure area • Health information, DOB kept separately

40. 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

41. Complete Policy and Procedure Manual • Must meet the needs and requirements of the accreditation provider you select • Not worth trying to create on your own at this point • Price Range $400 - $4000

42. Common Items Found Deficit • 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

43. Fact: Your P&P should have everything you need to meet accreditation guidelines You need to AUDIT your files and make sure they are complete LONG BEFORE your survey Reality

44. #2 Infection Control What Happens?

45. 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

49. What Other Problems with Infection Control/Safety Issues Are Found? • Infection Control: • Clean vs. Dirty- Warehouse, trucks • Handwashing • Chemicals scattered throughout • Labeling/placarding • Fire drills not conducted annually • Fire extinguishers not current • Stacks of forms/trash • Trucks not clean, up to date on maintenance

50. Fact: Infection Control is one of the main tenants of accreditation You can not review enough A revisit is really the only way to observe if infection control practices are being observed Reality