The NEW Most-Commonly Cited Standards

Posted by Steve DeGenaro on Wed, Oct 07, 2020 @ 04:09 PM

Blog-PZclipboardSurveyors for all the accrediting organizations are back on the road now, surveying up a storm and working to catch up the backlog of new customers and ongoing customers who were scheduled for survey in that March to July 2020 time period. It’s good to be back doing what we love, even with some accommodations and new processes in place.

Having been back to surveying for almost two months now, I’ve noticed –anecdotally, at least-- a few trends in deficiencies. Some of the standards we are citing are consistent with pre Covid trends, but a few are different. I thought it would be worthwhile to list out the most commonly cited standards; in the hopes that reviewing the list will help other organizations better prepare and better maintain their level of compliance regardless of when they are due for survey.

To accomplish this, I reached out to several of my peers and compared notes. This is not an “official list” but rather the combined experiences of several surveyors who want to help organizations improve. Take it for what it’s worth and remember: it never hurts to double and triple check to make sure you’re doing things the right way!

Here are some of the new most commonly cited standards: 

ORG 2—Expired State Licenses  As expected, some state licenses expired. Check all your state licenses to ensure they are still current. Pharmacy and Home Medical Equipment Licenses are the obvious ones we think of right away. But there are also State Bedding Licenses and various licenses to dispense or repackage oxygen in some states. If you expect a delay in receiving a new license, save documentation that you have re-applied. If your state has waived or delayed re-application, save documentation of the waiver or the delay.

HR 2—Competency Assessment   Some organizations expressed concern about re-assessing the competency of employees during the Pandemic. If you delay a “due” competency assessment, be sure to document the why behind the delay. Rather than delay, consider doing “virtual” assessments using Zoom or similar technology.

HR 5—In-Service Education   Again, it is easy to understand why gathering all the staff together in a small conference room isn’t a good idea in our post-Covid Pandemic workaday world. But there are options. Utilize conference calls, Zoom meetings, and on line learning to comply with this standard. While this standard was problematic at several organizations I visited, I also was impressed at the approach several had taken. One place that did a lot of retail experienced a tremendous slowdown in orders and customer traffic. They used the time to craft new in-service programs. As they got back to normal, they rolled out the new educational offerings and received extremely positive feedback from staff who appreciated how the topics were “freshened up” (as one employee had put it).

QM 1 – Quarterly QI Reports   Some organizations let the required quarterly quality improvement meetings and reports slip to the back burner. If you were tempted to do this because of gathering people in a room unnecessarily for a meeting, I’ll remind you that Zoom meetings can help you avoid that risk while staying compliant. If you back-burnered the program to prioritize patient care, it’s time to play catch up! Insert an explanatory narrative note in your QI meeting minutes if there are time discrepancies or missing meetings to note.

BC 1-3 – Billing & Collections   Insurance companies and Medicare relaxed certain requirements during the Pandemic. They also granted new provider status to organizations without the usual vetting (including accreditation). As we return to normal, remember to go back through all billing files with a fine-tooth comb. Correct any issues. In the case of one organization I visited, I recommended they increase the number of billing files they audited on a monthly basis. Make sure you’ve gathered all the appropriate paperwork and documentation. If you find errors, correct them ASAP.

PS 2 – Physician Orders   This requirement didn’t go away. You still need a valid, complete prescription for any legend items you are dispensing. Many referral sources are experiencing staffing shortages and increased workloads because of the Pandemic and Covid’s financial repercussions. In some cases, you may have seen the quality of the orders slipping in terms of compliance as busy offices tried to quickly discharge patients. Hold the referral sources accountable and make sure you have solid, legal orders for your protection and the protection of the patient/customer.

PS 6 – Verification of Receipt by Customer of Educational Materials   Worth mentioning in this discussion is the issue of patient/customers signing off on acknowledgements that they were educated and received not only their equipment and supplies, but also educational material relating to the equipment/supplies and other services you offer. In fact, consider this general advice for any forms or documentation that requires patient signature. In the post Covid era (at least for now), many organizations have shifted –rightfully so—to a paperless, touchless, contactless delivery model. Amazon, food delivery, and a multitude of other delivery services have shifted to this model as a means to prevent the spread of Covid. If you’re company is doing this, be sure to document on the forms why the patient hasn’t signed. Many companies are writing “Covid”, which probably makes pretty good sense because it is a universal explanation. Go back later and obtain a signature when you can. Be sure to leave written instructions and make sure the patient/customer understands everything. You can “get a pass” on collecting an actual signature, but you aren’t off the hook with regards to the instruction you give. Again, this applies to not only PS 6, signing off on the patient information packet, but also any place or form where you have a patient/customer sign a document.  

Finally, let’s also remember another issue that comes up: expiration dates. Expiration dates for various products, cleaners, and PPE must be monitored and the expired product, cleaner, or PPE should be removed and replaced at or before the date it expires. This issue can be seen in several different standards including ICS, DEL, and even RETAIL, depending on where the expired material is found. Expiration dates have passed during the Pandemic. Be sure to check handwash solutions, eyewash, cleaners and disinfectants, any creams or lotions on retail shelves, plus supplies that expire such as diabetic test strips, some catheters, and tracheal tubes.

These issues aren’t completely unique or related to the Covid Pandemic, but they are issues that have come up a little more often, and are therefore worth scrutiny regardless of cause and effect or how they are related to Covid. The list is a good place to start. Regardless of where you are in your accreditation cycle, consider running a self-study mock survey within your organization. As we move toward “back to normal”, make sure you’ve corrected areas that may have slipped a bit during the crisis. Here’s hoping we’re back to normal soon!


Topics: Employee Training, Renewing Accreditation, HME Accreditation Requirements, Avoiding Deficiencies, Competence, Surveys