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Accreditation/compliance: Maintain complaint log

Accreditation/compliance: Maintain complaint log

Mary Ellen ConwayQ. Why does my accreditor tell me that they or CMS may conduct an unannounced survey anytime during my three-year accreditation cycle and how common is that?  

A. When the accreditation mandate began for DME in 2008, the DMEPOS accrediting organizations (AOs) that were approved by CMS for Medicare participation had a requirement to inform their accredited organizations that they would be subject to having an additional unannounced survey by the accreditor or by CMS at some point during their three-year accreditation period. It was meant to confirm compliance. Additionally, Supplier Standard No. 8 states, in part, that "the supplier permits CMS or its agents to conduct on-site inspections to ascertain supplier compliance." The AO can be interpreted to be CMS's agent. We saw this happening more so at the start of the accreditation mandate than we have seen it lately but know it could happen at any time.   

One of the reasons that a non-renewal survey may happen is that CMS received a complaint that they then ask the accreditor to investigate. The complaint could have come directly to the accreditor themselves, as well. If this occurs, one of the first things the surveyor might ask to see is your complaint log. Supplier Standards 13,19 and 20 address complaints and the requirements that suppliers must meet. On an unannounced survey, you should be able to show that your complaint log is active. Maybe the investigation is looking to see if that particular complaint has been received and that you have documented it. Perhaps they might be looking to see if this type of complaint had been made before and how it was remediated. Maintaining your complaint log is just another good practice to ensure you remain compliant with your accreditation standards.  

Mary Ellen Conway is a nurse-health care consultant and president of Capital Healthcare Group. She can be reached at


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