Top Accreditation Deficiencies and How to Avoid Them

Posted by Curtis McLees on Tue, Aug 21, 2012 @ 01:27 PM

health_safety_crosswordThis year, many companies will be renewing their accreditation for the first time. If you’re renewing your accreditation, the last thing you want to hear come out of a surveyor’s mouth is the word “deficiencies.”

After reviewing the renewal survey information, we have found that there are a few deficiencies that seem to be cited regularly. Below we show you some of the top accreditation deficiencies and how to avoid them.

1. Document the required six hours of annual education.

Often it is not a matter of conducting the education, but properly documenting that the education occurred. When conducting the education, take a moment to document:

  • Any instructional materials provided
  • The sign-in sheet listing the subject, date and attendees

These two things are all that is needed to verify that the education occurred. This simple step should be a routine process with every educational program you conduct. 

2. Documenting annual competencies and employee reviews.

These certainly take time, but are necessary. Both competencies and evaluations can be very valuable tools to use to provide feedback for both the employee and management. Management can take these two tasks and turn them into strengths of the organization.  

If deficiencies are found, you will need to file a plan of correction, have the plan approved, complete a re-visit (if needed) and successfully be reaccredited in adequate time so that there is no lapse or gap in your accreditation status. Instead, plan ahead, take some time and ensure that deficiencies aren’t a possibility.

 3. Collection and Review of Quality/Program Improvement Data

Most often companies will have files or envelopes of customer satisfaction data but no follow up indicating that there has been discussion, review and/or change as a result of the information received. Making time for regularly scheduled meetings to review the points of data collected as defined by standards is intended to bring possible improvements to the forefront. 

4. Keeping all licenses, permits, certifications up to date

Keeping up with expirations of all of the above, which includes your accreditation date, revalidation dates, etc. can be daunting. Creating a spreadsheet with all descriptions of the items and their validation dates (from/to) can help to ensure that nothing expires.

Use a task-reminder system and place each item on your calendar two to three months ahead of expiration, for example, to systematize your renewal for each.

5. Standardizing the organization of personnel files

This is an area that can get out of control quickly. Begin your organization of files by creating a checklist or an audit sheet. Each file chould have this sheet as it's first page for example. Look through the file, check off what's within it and seek those items that are missing.

This same audit sheet could also include when licenses or certifications for certain staff are due as well.  Set specific times to review the audit sheets during the year, i.e. quarterly.

 Download the Compliance Calendar template

Topics: Renewing Accreditation, HME Accreditation Requirements, Compliance