Doublechecking Your Processes to Avoid the Top 10 Survey Deficiencies
When a site surveyor finds an accreditation deficiency, it's not the end, but rather a means to the end of improving your HME business's quality. Here are 10 deficiencies to keep in mind.
- By Jackie King
- Aug 12, 2021
Inspect what you expect.
Accreditation is the threshold,
and quality that outshines is the
outcome of meeting that threshold.
When you enhance your internal
audit tools using a partnership
with your accrediting organization,
you gain agility and stability.
Operational strength and process
standardization are the building
blocks of clinical distinction and
During the accreditation
process, once a provider tells its
accrediting organization that it
is ready for its site survey, the site
surveyor can come at any time. He
or she will arrive unannounced
and engage in a thorough,
methodical process to ensure the
business is compliant.
The COVID-19 pandemic has
impacted the site survey component
of the accreditation process in that
they are now handled remotely.
Currently, CMS requires AOs to
perform an on-site survey within
six months to a year after the
virtual site survey.
As your organization grows,
your needs change. Complexity,
expansion, regionalization, and
customer trends can impact your
processes. As you conduct your
routine audits and evaluate
processes and changes – here are
the top ten deficiencies found by
CHAP surveyors while on-site.
Operates in compliance with local, state,
and federal regulations. Ensure all applicable
licenses are current. Ensure staff
are knowledgeable of local, state, and
federal regulations and operate within
Infection control policies include written
schedules and protocols for cleaning/decontaminating
equipment and work surfaces.
Perform periodic audits of cleaning logs to
ensure cleaning/decontamination processes
are being performed per organizational
policy and documented within required
timeframes. Ensure equipment is being
cleaned on non-porous work surface.
Medical gases are stored, transported,
transfilled and tracked according to
regulation. Perform periodic inspections
of oxygen storage and delivery vehicles to
ensure oxygen is being stored and transported
per DOT/FDA regulations. Perform
field observations with staff to ensure
processes are followed and required
documentation has been completed.
Infection control practices are in place,
including handwashing and handling
contaminated equipment. Periodic
review of policies to ensure it includes
current infection control practices for
handwashing, use of PPE, handling/storage of contaminated equipment, and
appropriate practices for decontamination
and cleaning of equipment.
Delivery of equipment. Periodic audit
of client records to ensure all required
documentation is completed. Periodic
field observation to validate appropriate
setup of items and client receipt of applicable
documents and training materials.
Service plans include all items. Perform
periodic review of client records to ensure
applicable service plans are on file.
Employee competency evaluation.
Perform periodic audits of personnel
records to ensure competency evaluations
are completed at the appropriate
timeframes and are on file.
Ongoing service/maintenance for rental
equipment. Audit client records to
ensure required maintenance for rental
equipment is completed timely.
Storage to protect from damage.
Periodic inspection of storage area and
delivery vehicles to ensure appropriate
storage methods are followed.
Equipment maintenance documentation.
Review maintenance logs to ensure
appropriate documentation of equipment
cleaning, testing, maintenance, and
repairs as required.
POINTS TO REMEMBER
- Simple CQI processes should be
part of your practice as they aid you
in improving your daily processes,
resolving problems, and improving
the quality of the products and
services you provide customers.
- Periodic checks and balances such
as audits, observations, and inspections
identify gaps in processes or
opportunities for improvement and
provide the information needed
to make corrections to maintain
compliance with accreditor standards
and regulatory requirements.
- Utilize these top 10 deficiencies
to benchmark your organizational
performance in these areas.
Remember to get your entire team
involved, as this is essential to
To read more about accreditation, visit
to learn more about CHAP standards,
visit their education page at www.chapinc.org.
Jackie King, RRT, has more than 35 years of experience and has been a CHAP Director of Accreditation guiding the accrediting organization’s DMEPOS providers for 10 years. She can be reached via email at Jackie.firstname.lastname@example.org.