Respiratory Solutions

Top 10 Accreditation Survey Tips

As America's home medical equipment and clinical respiratory providers gear up for mandatory accreditation — the deadline is Sept. 30, 2009 — many organizations have questions about how to best prepare for their survey.

No matter which of the 10 deemed accrediting bodies an organization chooses, the standards have some commonality and are linked by the Centers for Medicare & Medicaid Services' (CMS) Quality Standards.

All of the accrediting bodies suggest an internal self-audit as an excellent means of assessing an organization's level of preparation and readiness for the survey. It is useful to know hot-button items and standards that are frequently cited as being deficient as you perform your own self-audit.

The following tips are based on frequently cited issues of non-compliance.

1. Make sure you have complete and accurate physician orders. Often organizations do not realize that orders for oxygen need to include liter flow and duration or that CPAP orders need to include pressure settings. Watch to make sure the chart is updated if the order changes based on a verbal order and make sure the order is updated yearly if required by law and regulation in your state.

2. Separate equipment into "clean, patient ready" and "dirty" areas according to your policy. Expect surveyors to tour your warehouse, cleaning areas, all equipment storage areas and the repair area. While most accrediting bodies allow your organization to define how you separate equipment, whether or not it is bagged or tagged or both, and how equipment flows through the various areas, they will expect you to follow your own policy.

3. Make sure your clean and dirty equipment is separate in delivery vehicles and showrooms. Often, customers bring used equipment back to your organization for return, exchange, refilling or testing/calibration. Make sure you have a process to keep this equipment separate from patient-ready, clean equipment and supplies. Also make sure you separate equipment in delivery vehicles.

4. Document staff competence assessments. Any staff that performs patient care (clinical care or delivery/setup/instruction of medical equipment) should have well-documented competency assessments performed at the time they are hired and on an ongoing basis. Competency assessments usually include in-service education programs, "check-offs," skills fairs and some kind of ride-along observational assessment. Make sure the person performing the competency assessment is qualified to assess whatever task they are observing. For instance, if respiratory therapists perform tracheal tube changes, the person performing the assessment should be a clinician capable of performing the task.

5. Does your staff have clinical licenses and driver's licenses that are up to date and current? A quick self-audit of your human resource files can answer this question. The surveyor usually looks for these items for a random selection of personnel.

6. Equipment maintenance records must be current and up to date. Surveyors will most likely pull some random pieces of equipment based on serial numbers they see on home visits or in patient charts and ask you to produce maintenance records for these pieces of equipment. Be sure you are following the manufacturer's guidelines for ongoing and preventive maintenance.

7. Where is all my equipment? Hopefully you know where your equipment is located and can demonstrate to the surveyor how you track equipment. Expect to explain how you track equipment to the surveyor. More importantly, be prepared to actually look up some equipment based on serial numbers the surveyor will give you from their own audit activities. Generally, any equipment with serial numbers should be tracked so that an organization can locate a piece of equipment in the event of a recall.

8. Check and stock vehicles. Make sure vehicles are equipped with personal protective equipment (PPE), hand-washing solution, fire extinguishers and cleaning supplies (if applicable at your organization). Keep vans or trucks clutter-free, neat and clean.

9. Practice safe patient care by washing your hands. Staff members who forget to wash their hands can spread infections to other patients, fellow staff members, their own families and themselves. Employees should wash their hands before and after every patient visit and after handling equipment or supplies that are contaminated.

10. Housekeeping. Simple housekeeping tasks can help to keep you compliant. Simply picking up clutter, emptying wastebaskets and dumpsters, sorting through stock items to pick out expired and obsolete items, and cleaning and dusting the warehouse and showroom can enhance patient care by making your organization more organized and efficient.

This article originally appeared in the Respiratory Management May 2009 issue of HME Business.

About the Author

Steve DeGenaro, RRT, is a 20+-year veteran of the home medical equipment industry and is the director of survey services for the accrediting body HQAA ( He can be reached at

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