Imagine you are either sitting down to hear a debriefing after your accreditation survey or opening up the report from your accreditation survey. In either/both cases, the surveyor or the accreditation agency will most likely be breaking down any areas of deficiency into issues requiring on site follow up or issues requiring written follow up. Different accrediting bodies call these categories by different names, but in all cases, they are essentially issues that you need another visit to clear or issues that can be cleared through some type of written follow up report.Staff members, managers, and owners from organizations that have been surveyed often misunderstand the reasons these deficiencies are classified into the categories into which they are placed. Is one more “serious” than the other? Is the final outcome of the survey delayed or withheld pending the follow up? How does the surveyor (or accrediting body) decide which category a deficiency should be placed into? Understanding the idea behind these two categories of deficiencies might be useful in planning for survey. Knowledge being power, let’s explore the two types of deficiencies.

Deficiencies Requiring On Site Follow Up:

Deficiencies that are placed here are usually related to at least one of these four issues:

• A SAFETY ISSUE OR CONCERN FOR PATIENT/CUSTOMERS: This can be major problems with equipment or incompetent staff performing important equipment functions such as maintenance or patient education.
• A SAFETY ISSUE OR CONCERN FOR EMPLOYEE/EMPLOYEES: Problems in the warehouse—we’re talking MAJOR problems such as unsafe oxygen storage or transfilling, extreme fire hazards, unsafe/unroadworthy delivery vehicles, etc. all fall into this category.
• FRAUD & ABUSE / DISHONEST BILLING PRACTICES: We are not talking about simple, rare mistakes filling out claims. These would be widespread billing inconsistencies, particularly when there is a suspicion of fraud.
• HIGH NUMBER OF DEFICIENCIES: Sometimes, it isn’t necessarily a major safety issue or fraudulent billing, but rather, the sheer number of deficiencies. There’s no magic number, but if your organization has a high number of deficiencies, the surveyor begins to consider that it might be helpful for a return visit to re-assess. If the warehouse and retail areas are a mess, the record keeping is sloppy, items are missing from human resource files and patient records, and a home visit uncovers issues, the sheer number of issues can earn your organization a repeat visit.

If another on site visit is required, that visit is referred to as a “focus visit” because the surveyor will be focused on those issues revealed in the first survey.

Typically, on a focus survey, the deficiencies are still broken down into these categories and your organization will be expected to respond to the deficiencies requiring written follow up first -- followed by your focus survey. There’s no hard-fast rule about how quickly the focus survey takes place. That depends on how many issues the organization has to correct and also how fast they can “fix” them. For matters of patient safety, the accreditation provider typically wants to see fairly speedy corrections since patient safety at stake.

Deficiencies Requiring Written Follow Up:

In short, all other deficiencies are placed here. It is tempting to think these are less serious issues and to some extent that might be true. However, these issues can be equally important and may be placed here because the organization can easily provide evidence to support correcting the issue. An example of this might be a missing state license. Not being properly licensed to provide DMEPOS in a given state is very important. However, the “fix” is simply to obtain said license. Once obtained, it is easy to show evidence without submitting to a repeat visit.

Written follow up can be done to show evidence of a revised policy & procedure, a newly developed form, evidence of staff competency assessment or training, results from chart audits, or documentation of a meeting or in-service education program.

The surveyor will explain the issue of noncompliance during the survey or at the exit conference. Ask questions and seek clarification if you don’t understand. The written report you receive days later will reiterate the deficiency and will also spell out exactly how your organization should respond to show evidence of correction. You have thirty days to disagree with the finding. Most issues can be corrected quickly and painlessly.

It is also worth mentioning that if you can correct an issue during the course of the survey, the surveyor will still document the deficiency, but can also place the deficiency in a special third category: “Deficiencies Corrected On Site”. Because these deficiencies were corrected before the surveyor left the organization and because the correction was observed, there is usually no additional follow up required.

Remember, too, that most accreditation bodies track deficiencies as first-time issues and repeat deficiencies. In some cases, the outcome and follow up required might be different if it is a repeat of a deficiency from the prior survey. In these repeat cases, your organization has an established track record of problems in this particular area. Subsequent, repeat violations of the same standard/same issue can sometimes cause additional follow up or scrutiny to demonstrate that the noncompliance is corrected once and for all.

Finally, it’s always important to remember that the accrediting body is pointing out deficiencies to help your organization improve. Whether you have written follow up to attend to in the days and weeks following survey or you have to prepare for another onsite visit, keep in mind that the goal is to correct your deficiencies so that you improve your operations. The accrediting body points these issues out and expects corrective actions because they are good business, efficient practices, and literally the law of the land!