Accreditation: Gather info beforehand

Q. What are some things I can do to prepare for my inspection?
Monday, February 25, 2013

A. Some accrediting organizations will perform a one-day inspection; others can take up to three days. 

To start, gather all of your licenses, permits, and surety bond and insurance documents. This includes any certifications you are required to have. Make a photocopy of each and put them in your “important documents” file. Be sure that all policy and procedure manuals are available to all staff for review if needed.

A business plan including a fiscal budget, projected revenue and expenses should be prepared to document responsible fiscal management.

Employee files should be reviewed for accuracy and updated regularly.

A sample patient file can sometimes make the surveyor’s job easier by showing them an example of what forms they should be looking for when they review your actual patient charts.

Your company should also be able to demonstrate some type of performance Improvement activity. As providers of healthcare services, we should always be seeking perfection in all of our activities to promote positive patient outcomes. We do this through review of our patient records, patient complaints, satisfaction surveys, billing error logs, etc.

An infection and safety control program will need to implement effective safety training, including fire safety, emergency preparedness and an infectious disease exposure control plan to all required staff. All personal protective equipment will need to be readily available in addition to cleaning agents. You must also have a clean and dirty area for equipment returns and/or exchanges.

Please keep in mind, this is not everything you will need for your inspection. There is a lot of time, patience, planning and detail that go into this. If you are not sure, it may be best to consult with someone.

Roni Pidcock is vice president of Quality Healthcare Systems. She can be reached at 855.747.5555 or