Accreditation time has come to your facility and you were not able to hide. The surveyor is at the door and wants to view your darkest and most carefully kept secrets. What does he need and how can you get through this thing with your hindquarters intact? Fear not, for most of the documentation they are looking for is already in your office. You simply need to find it.

As a facility accreditation surveyor for the The Board of Certification/Accreditation (BOC) over the better part of the last 7 years I can tell you that what I see in each facility can vary wildly. Most facilities are more ready than they think but each one has a different idea of what the surveyor is looking for. Over the next few articles we will be discussing how to prepare for the different aspects of accreditation and what the accreditation standards mean to you.

Standards are for everyone

First, let’s talk about the standards. Standards are just that: standard. They are uniform regulations that everyone must follow regardless of how small your facility might be or how few people are employed there. Some of the standards seem pointless but rest assured that each has a reason behind its seeming madness. We must each follow the standards regardless of whether we feel we should be subject to them or not. Getting them changed is a topic for another article.

When a surveyor comes to visit, which he or she will do approximately every 3 years, don’t panic. As the saying goes, “We are with the government and we are here to help.”


Steve Hill


Most people think that the surveyor is looking for the things that you are doing wrong or are not doing at all. This is not usually the case. Most good surveyors want to help you come into compliance rather than bust you for things you are not doing. Let’s face it, there are a lot of standards to understand and many of them are not easily understood. Your surveyor is part of your compliance team and can answer any questions you may have and should be able to help you understand the regulations you are facing.

This is not to say that you shouldn’t consider hiring a consultant to help you get your ducks in a row. A good consultant will be able to provide you with all of the necessary manuals, forms and logbooks that the surveyor will be looking for. The best consultants can also provide you with a framework of regular maintenance that must be done during the course of your business year, and may email reminders to do things like audit patient files and document performance management. The experience and advice they can offer you is usually worth the money you pay them.

Be prepared

This article relates to things you need to get ready before the surveyor walks through your door. You can use this as a sort of to-do list so that the papers required will be handy for the surveyor when he asks for them and you won’t waste valuable time rummaging through your filing cabinets.

A proper survey can take 2 or 3 hours when all the paperwork is available or it can take 6 hours if you have to hunt for everything. If you must find each contract one by one and make a dozen phone calls requesting various proofs of documentation, your survey will take considerably more time. Data collection is best done before you submit the application and the surveyor arrives. The surveyor’s time is as valuable as yours, so everything you can compile now will save you both lots of time on survey day. Future articles will deal with each of those categories individually.

Using this list should greatly simplify and expedite the survey. If there are items on this list that are not available at the time of survey, again, DON’T PANIC! These are usually not pass or fail surveys and you should be given a nominal amount of time to send in the documentation you lack.

The part of the survey that may cause you the most consternation deals with the facility itself. If your building is not compliant, that can be a problem. The surveyor can show you how to fix your equipment maintenance log but he can’t install an elevator to your second floor office space to make it compliant with the Americans With Disabilities Act (ADA). If your facility was acceptable for the first survey, it should be fine for future surveys so that shouldn’t be a problem for you. If this is your first survey or if your facility has undergone serious changes recently, simply comply with the ADA requirements and local zoning and you will be fine. If the facility itself does not pass the accreditation standards you may get another visit. This will likely incur additional costs to send another surveyor to visit, so make sure your facility is up to snuff.

The list

The following list can, and most likely will, change depending on how the Centers for Medicare & Medicaid Services (CMS) aims its focus, but it should suffice for the near future. For the most part the surveyor will ask to see manuals, logs, files and paperwork. The manuals need to be onsite, available and complete. You can fax a copy of your liability insurance and you can fax your 236-page policies and procedures manual, but not without making some enemies. The same thing goes for the logs. They should be onsite and current.

Most of the files and paperwork are easy enough to have handy, but things like current financial documents can be elusive at times. We occasionally hear that the accountant has this paper or they keep that file at home for security. Most accrediting bodies acknowledge that these things can happen. After all, it is a surprise, unannounced visit.

What the surveyor will be looking for includes, but is not limited to:

Manuals. Policies and procedures manual, HIPAA compliance manual, emergency plan, performance management plan (and all of its constituent parts) and the MSDS book.

Documents. Current profit and loss statement, balance sheet, operating budget and bank statement, all contracts and letters of credit, OIG exclusions list, insurance documentation, invoices for goods supplied.

Facility. Properly outfitted lab, properly outfitted patient care rooms, ADA compliance, a fire marshal inspection (if available), appropriate first aid provisions and an appropriate stock of supplies.

Logs. Equipment maintenance logs, serial number logs, complaint/communication log, billing and coding errors log and adverse events log.

Files. Approximately five to 10 Medicare patient files with EOBs and all employee files (including the owner’s).

An ever changing landscape

Always remember that surveys and surveyors can vary from accrediting organization (AO) to AO. Because the first surveyor didn’t ask for something doesn’t mean that the next one will not. The survey experience will almost certainly be slightly different each time, even if you are blessed with the same surveyor.

Consider these variables: there are 10 AOs, each one with a different background and focus. The Board of Certification/Accreditation, International (BOC) and the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) are, of course, O&P-centric, but there are others with respiratory therapy backgrounds, DME backgrounds and hospital backgrounds. Each organization must implement the CMS standards but each one also brings its own accreditation standards with it and we must comply with all sets of standards.

Add to that many other variables, such as the personality and experience differences among surveyors, differences found among multiple training sessions, the changes over time of the standards and the ever-changing focus of the CMS. As much as each AO strives toward and would like to see its surveyors perform identical surveys, it simply isn’t possible. Bear in mind that your surveyor, or most of them, are people too and are doing their best.

Future installments of this series will cover each section in more detail and try to help you breeze right through your next survey. Although the standards may be numerous and seemingly pointless they are easy enough to wrap our arms around if we simply realize that there is no getting around them while still accepting Medicare assignments.

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