Top Ten Deficiencies & How to Prevent Them

Posted by Steve DeGenaro on Wed, Mar 08, 2017 @ 11:33 AM


The nature of accreditation is that a company embraces a continuous quality improvement methodology and operates its business in compliance with laws, regulations, and industry best practices to the best of its ability. Accreditation is a journey not just a destination – a journey full of learning opportunities, education, and revision and tweaking of your company’s processes and procedures.

That process doesn’t lend itself well to quick “punch lists” and it is not advisable to look for shortcuts along the journey. However, companies going through the accreditation process and the surveyors who inspect those companies often talk about commonly cited standards and top deficiencies to try to avoid. Certainly, a top ten list of commonly cited deficiencies can be thought of as a good place to start on the road to accreditation, re-accreditation, or even simply on the road to improvement in general.

The following list includes ten commonly cited deficiencies along with very succinct advice on how to prevent them in your organization. Reviewing these issues in your company as you begin your journey toward accreditation is a good start. Furthermore, reviewing these issues if you are an already-accredited organization is a useful exercise to assess how well you are keeping up with accreditation standards (and therefore “quality”) within your organization.

ORG 2 - Complying with Law, Regulation, & Licenses: In short, comply with all law and regulation. Prior to survey, surveyors will check on state law and regulation in the HME industry with careful consideration of state HME licensure, state Board of Pharmacy licensure, and any other state license you may need based on services offered. Also, be sure to comply with federal guidelines including the Supplier Standards, OSHA, and DOT regulations. Finally, if you are providing any kind of respiratory therapy equipment or clinical service, make sure you are following the American Association of Respiratory Care (AARC) Clinical Practice Guidelines.

HR 2 – Competency Program: Competency of staff is crucial to not only accreditation but also to the success of your business. If you use staff that isn’t competent, you risk liability for their incompetent actions. This particular standard is where surveyors cite issues with actual staff competence. It is also (and much more frequently) the place where they cite inadequate documentation of staff competency assessment. Your program should assess each and every staff member’s competency to perform their job at hire and annually. Typically, these assessments become part of a personnel file. Make sure you use appropriate staff to make these assessments. For instance, if a respiratory therapist is doing something clinical in nature, a non-clinician would have a hard time assessing how well they are performing.

HR 8 – Personnel Files: This standard is a catch all for issues of missing documentation in a personnel file. In reviewing the personnel files, the surveyor will look for an application for employment, training/orientation documentation, a signed job description, and performance appraisals. Also, be sure I 9 forms are correctly filled out and available for inspection. Health records should be stored separately.

ICS 2 – Maintaining a Clean Safe Work Environment: This standard includes several items that surveyors look for while touring the facility and observing work flow. Make sure you have fire extinguishers placed strategically in equipment storage areas. Make sure you have posted exit strategies –maps that highlight how to exit a building or area in the event of an emergency. Make sure you have appropriate safety equipment including first aid kits available.

QM 1 – Quality Improvement Program: Your “QI” program should include all the required indicators and a thoughtful study of each of them. Collected data to support the studies should be available for inspection, as well as notes and minutes for quarterly meetings as well as annual overview summaries. The meetings should discuss results and plan for improvement based on the results.

PS 2 - Physician Orders: In several studies where it was measured, across multiple accrediting organizations, this issue was a consistent problem for many companies. Your organization needs to keep careful documentation of physician orders for any and all equipment and care provided. Clarify orders when they are confusing or unclear. Have a solid, workable process to ensure that orders are updated when required. In many states, orders must be updated annually.

PS 6 – Client Medical Records: This standard is a catch all for missing documentation in the patient record. Like HR 8 for personnel files, it’s a laundry list of things the medical record should contain. Required items include verification that delivery took place, patient’s signature on acknowledgements for training, warranty information, and HIPAA, as well as a plan of care or service. Updates to the plan of care as well as subsequent follow up documentation should be available and organized into an easy to follow format.

MM 1 – Warehouse: Surveyors use this as a place to cite issues with separation of clean and dirty equipment. Warehouses should be clean, safe, well marked with signage, and free of hazards. Obsolete equipment should be segregated from general inventory and kept in a separate and marked area. Cleaning and repair areas should be well marked as well.

DEL 2 – Delivery of Equipment: Surveyors will assess the vehicles to make sure they are safe and that equipment is transported appropriately. This standard is where the vehicle itself is assessed but also where the delivery process undergoes scrutiny. Well marked areas and a procedure for keeping equipment secure and separated during transport is important and must be followed during survey. Expect that the surveyor will not only look at the vehicle and inspect it in your parking lot, but will also ride along on a delivery to observe how the process is actually followed.

RT 4 – Product Placement in Retail Area: The retail showroom should be neat and clean and equipment on display should be staged in a safe manner. Frequently, organizations are cited because they do not have pricing available for equipment on display. Be sure to have prices on everything that is for sale in the retail area. Also, be sure to have an area for returned equipment brought back in by patient/customers. This equipment should be considered “dirty” and kept separate from the clean equipment and supplies.

Peter Drucker—noted management consultant often referred to as the “founder of modern business management” -- famously said, “Plans are only good intentions unless they immediately degenerate into hard work”. Once you’ve identified areas of noncompliance, the real work is fixing the issues. Complying with this list of ten commonly cited standards won’t make your company perfect, but it’s a good place to start.


Topics: Quality Standards, HQAA Accreditation, HME Accreditation Requirements, Compliance, Avoiding Deficiencies