Thursday, July 31, 2008

Q. As an accreditation inspector/surveyor, what common problems or deficiencies do you see during HME surveys?

A. I see four typical problem areas.

- Fast tracking: Many companies with numerous deficiencies and problems have not taken the time necessary to prepare for their survey. The process cannot be rushed.

- Policy and procedure (P&P) manual: You may write your own or purchase one from an outside vendor. Be sure that you review every policy as written in this manual and that these policies are specific to your company. If your accrediting organization requests copies of specific policies prior to your survey, be sure that you review them before submission. If you find policies and procedures for services that your company doesn’t provide, remove them.

- Quality management (QM): During the inspection, the surveyor will interview your QM person(s) and review all related documentation. Therefore, it’s important that all employees responsible for this program understand their responsibilities. You must also include the required documentation as outlined within your P&P manual. It is also a good practice to identify QM personnel in your organization chart. Additionally, these employees should have a signed job description for this position in their permanent employee file.

- Compliance: Be sure your compliance person(s) has knowledge of their responsibilities and can provide documentation as outlined in your P&P manual. As with your QM program, this is an ongoing process and all documentation needs to be presented to your management as outlined within your policy.

Industry consultant Bob Weir is an accreditation surveyor and president of Weir & Associates. Reach