Accreditation: View corrective action as opportunity

Q. Should I be concerned if my accrediting organization requests additional information or corrective actions following my site survey? 

A. Many businesses require some follow-up after the site survey is completed and before accreditation is awarded. The follow-up may include items such as: submitting additional documents, adding signage and moving supplies to a different location. When an AO requests corrective actions, don’t view it as failure. It is not unusual for a business to make needed adjustments to verify compliance following the site survey. And, if you have selected an AO that is invested in your success, their staff will be prepared to help you understand CMS requirements so that you can get accredited. 

Here are three of the most common areas that require corrective actions after a site survey: 

Incomplete insurance certificates  

Both your AO and the National Supplier Clearinghouse (NSC) must be listed “certificate holders” on the insurance certificate. To resolve this issue, ask your insurance company to add the NSC and AO to the certificate and send a copy to your AO.  

Outdated financial documents 

Maintaining a detailed record of your financials, including income statements, balance sheets, operating budget, product invoices, and current bank statements, is imperative for successful operation. If these documents are outdated or missing, your facility is out of compliance. 

Missing personnel files  

Detailed HR records assure CMS that your organization has the right personnel, appropriate training, active certification/licensure (when applicable), and experience necessary to provide care to your patient population. Refer to Section 1, Part C of the DMEPOS Quality Standards for information on compliant personnel files or ask your AO for assistance. 

Addressing corrective actions can be as simple as producing well-organized and detailed documents. If you are having trouble resolving any issues identified in your site survey, contact your AO for guidance. Remember, corrective actions are opportunities to confirm your commitment to safety and compliance and earn accreditation.  

Matt Gruskin is the credentialing director for BOC. Reach him at [email protected].