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Accreditation: Verify licensure, policies 

Accreditation: Verify licensure, policies 

Harold DavisQ. I am preparing for an accreditation site visit. What areas should I focus on? 

A. This question is asked often when organizations are preparing for surveys. Organizations need to be certain that all the required licenses are up to date and displayed as required. Licenses you may need include state, local city and county licenses. Also, don’t forget to have a current copy of anyone’s driver’s license who drives a company vehicle and to verify any professional licenses.  

The organization should be sure that they have a current copy of their liability insurance, as well as the Medicare surety bond. Some states also require a Medicaid surety bond so be sure to check your state requirements.  

Depending on the accreditation organization standards, verify that competency assessments and employee performance reviews have been completed as required by the accreditation standards or your policy. In all cases, if your company policy requires items to be completed more frequently than the AO standards requirement, you will be held accountable to your company requirements.  

Remember that your surveyor will review your quality management program, so be certain your reports are up to date. One of the most important things you can do is to walk through your warehouse with a fresh set of eyes. Inspect areas that you don’t usually pay attention to. Verify that items are covered, tagged or maintained according to your organizational policy. Ask yourself: Are items stored in the proper areas? Do you have designated areas for patient clean, contaminated, broken equipment, repair, etc.?  

Don’t forget to check on the disinfecting and testing of equipment and that it is being performed per manufacturer guidelines. Inspect your delivery vehicles for items like flowmeters stored in the doors and glove boxes unprotected. Review vehicle logs to ascertain they are current. Lastly, know your policy and be sure that what you say you do, you actually do. 

Harold Davis is director of survey services for HQAA. Reach him at


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