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.

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 growth.

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 those parameters.


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.


  • 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 sustainable improvements.


To read more about accreditation, visit, and to learn more about CHAP standards, visit their education page at

About the Author

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

HME Business Podcast

Latest Podcasts