Prepare for Unannounced Facility Accreditation Surveyor Visits

Albuquerque, N.M. — Chrissy Heckenberg, director of facility
accreditation at the American Board for Certification in Orthotics, Prosthetics
& Pedorthics, and Wendy Miller, BOCO, director of facility accreditation
for BOC International, reviewed current accreditation guidelines at the
Pedorthic Footcare Association 52nd Annual Symposium and Exhibition. Heckenberg
and Miller discussed how facility owners and staff can prepare for the
unannounced facility accreditation site

“The first thing you want to do before you apply for accreditation
is review all of the standards and be prepared,” Heckenberg said at the
symposium. “It’s very important that you submit all of the required
documentation when you submit the application. Make sure it is complete.
Missing information on the application will hold up the process. We actually
see this often.”

Correct deficiencies

By correctly submitting the application forms, the facility implies that
it is compliant and ready for a survey. As mandated by Medicare, surveys are
unannounced and unscheduled. Facilities that are reapplying should make sure
they have reached out to their accrediting organization several months in
advance so they have time to review the application, process it and assign a
surveyor to the site. Facilities should plan ahead in case there is incomplete
paperwork or an action plan is needed to correct deficiencies. If there are
discrepancies, they must be resolved before the expiration date. ABC contacts
facilities 8 months in advance by sending a series of emails and letters. BOC
begins sending out letters 9 months in advance. BOC will send out letters 9
months, 6 months and 3 months prior to the expiration date.

“When preparing for a survey, begin with informing your
staff,” Miller said. “Make sure they understand the importance of the
survey. You also want them to know where to find the proper documents the
surveyor may be looking for.”

Surveyors often ask to see policy procedure manuals, MSDS manuals,
performance improvement reports and patient charts. Make sure those items are
complete and readily available. According to Miller, performance improvement
documentation will be subject to a detailed review.

“Designate a staff member to assist the surveyor,” Miller
said. “Pick someone who is accountable and has the credentials to obtain
the financial paperwork and patient files.”

Impeccable documentation

Miller suggested that facility staff review previously conducted
surveys. Surveyors will analyze corrected actions to confirm that they are no
longer an area of concern. Surveyors will also inspect every aspect of patient
care documentation and sift through charts, notes and uniform documents that
every facility should have and disclose to their patients.

“Documentation is the key to validation,” Heckenberg said.
“Patient chart notes are the most important aspect of business. Have you
documented the delivery of an item? The initial evaluation? We are looking for
specific notes.”

Patient charts

Medicare introduced a quality standards booklet, DMEPOS
Quality Standards Booklet
, describing exactly what needs to be in
patient chart notes. The booklet is a valuable guide for all facility managers,
according to Heckenberg and Miller. ABC will review and confirm patient care
charts by contacting patients via phone while at the facility for the survey.
BOC will also gather pertinent information and interview patients who are
onsite; patient phone interviews will be conducted offsite.

“This is a Medicare requirement, but we are not trying to be
intrusive,” Heckenberg said. “We are calling to make sure the patient
has received what he or she was billed for. Every once in a while we run into
an issue. Do not panic. We call on behalf of the facility. We phrase it in a
way not to alarm your patients.”

In order to avoid the inconvenience of
RAC audits or increased paperwork due to incomplete records,
make sure your facility is compliant and continually documenting patient care

“RAC auditors are getting a commission based on what they bring
back,” Heckenberg said. “Nine out of 10 times it’s because of
incomplete chart documentation. Make sure you are documenting.” —
by Anthony Calabro

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