Washington Update
With competitive bidding now codified into the law, more than a few providers favor accreditation as a way to level the playing field among potential bidders by adopting quality standards that all HME companies must meet in order to qualify for a share of the Medicare durable medical equipment market.
No matter which accrediting organization your company chooses, there are some basic standards that each share in some form or the other.
The Medicare Prescription Drug Improvement and Modernization Act of 2003 will result in many changes for the home medical equipment industry most of which were vigorously opposed by industry providers, associations, and even home medical equipment patients. However, one aspect of the newly enacted law, mandatory accreditation, has been championed by many?and it's easy to see why.
With competitive bidding now codified into the law, more than a few providers favor accreditation as a way to level the playing field among potential bidders by adopting quality standards that all HME companies must meet in order to qualify for a share of the Medicare durable medical equipment market. Mandatory accreditation is one of the few provisions of the law that lacks a designated timeframe for implementation, but it is reasonable to assume that some form of accreditation will be required before competitive bidding takes effect.
Currently, home medical equipment providers seeking accreditation have three accrediting bodies to choose from: the Joint Commission for Accreditation of Healthcare Organizations (JCAHO); the Accreditation Commission for Healthcare (ACHC); and Community Health Accreditation Program (CHAP). The differences among these accrediting bodies are minimal in many respects. They share the same basic accreditation standards; they each accredit organizations in three year cycles; and all three reserve the right to conduct random unannounced surveys at their discretion. The costs charged for an accreditation survey are fairly similar as well, although JCAHO and ACHC have an arguably more straightforward, less complex method of calculating fees charged to the provider.
How do you choose an accrediting body? Some insurance payers require accreditation as a condition of their contracts with providers. The choice should depend, in large part, on which accrediting organizations are recognized by other payers your company contracts with or hopes to contract with in the future. JCAHO, having had many years head start on their competitors, is recognized by nearly all insurance payers. However, ACHC and CHAP also have gained wide recognition by more insurance payers in the past few years. If insurance payer preference isn't an issue, the choice largely comes down to the personal preference of the HME provider seeking accreditation. In that instance, your best bet is to take the time to speak with representatives of all three accrediting bodies and briefly review the basics of their individual requirements for accreditation before making a decision.
No matter which accrediting organization your company chooses, there are some basic standards that each share in some form or the other. Even if you don't plan to seek accreditation in the immediate future, your organizations can, and likely should, take some steps toward accreditation so that it is able to more easily meet mandatory quality standards when the times comes.
Physician Orders
Having current and complete physician's orders are a number one priority to accrediting organizations and must include complete details of the equipment to be provided and any specifics as to how that equipment is to be used. Oxygen orders, in particular, should include route, dosage and frequency. For instance, "oxygen at 2 liter per minute," will be seen as an incomplete order. A complete order, according to accrediting body standards, would instead read, "Oxygen at 2 liter per minute, via nasal cannula, 24 hours per day." Using standard medical abbreviations is fine so long as all the components of a complete order are present. Remember also that the order must include for the provision of any extra devices that are added to the patient's regime in the course of treatment, such as conserving devices for oxygen or heated humidifiers added to CPAP devices. Device settings should also be explicit and reflect the physician's current instructions to the patient.
Most HME providers dispense and deliver equipment based on a verbal order from a referring health care professional, but obtaining a detailed written order in a timely fashion after the delivery is complete, is a critical component to a successful accreditation survey. As all HME providers know, getting requested documentation back from referring physicians can be a difficult and time consuming process. You can make the job easier for the physician and encourage a speedier return if you obtain all the information you need for the detailed written order during the intake process. Once you have obtained a complete verbal order, it can be reiterated in its entirety on a written order form by your staff and then sent to the physician who only needs to review, sign and date the prescription to confirm that it reflects what was ordered verbally. Even then you may not get signed orders back from physicians in as timely a manner as you may like. Make sure you can show the accreditation surveyor that your organization does in fact have a consistent and timely process for following up on orders that have not been signed and returned from physicians.
Plan of Care / Assessment
Patients who are prescribed rental equipment on a recurring basis, particularly respiratory equipment, should have some type of plan of care in their patient file that reflects an assessment of their risk factors. This plan may signal the need for further intervention in the future and it should document that the patient has been instructed on safe use of the equipment provided. If the patient's prescription changes, or the patient demonstrates knowledge deficits on the use of the equipment or a lack of compliance with the current prescription is uncovered during follow-up home visits, this plan of care should be updated to reflect changes to the plan of care and/or the provider?s attempts at re-education.
Remember that accreditation surveyors will accompany staff on home visits to set-up new patients and on follow-up visits with existing patients. Observation of these home visits will factor quite heavily into the accrediting organization's assessment of the quality of the patient care your company provides. You can help patient care staff members shine in this area by providing them with written patient education materials that serve to remind them of the important points to cover when instructing patients. As a bonus, leaving the written information in the home when the instruction is complete will likely cut down on calls from patients bewildered by their new equipment the moment your staff member leaves the home. During follow-up visits, your patient care staff should focus not only checking the functionality of the equipment, but also on asking open ended questions of the patient or caregiver to determine if the equipment is being used in compliance with the physician's order. For instance, instead of asking Mr. Smith if he is using his oxygen at night as ordered, ask Mr. Smith how often he is using his oxygen. By using open-ended questions during the follow-up assessment, patient care personnel can uncover problems that may require reeducation. And by all means, document, document, document. The old adage, if it wasn't documented it wasn't done, is never more true than during an accreditation survey.
Routine Maintenance and Equipment Tracking
One of the main areas where your company will be evaluated during an accreditation survey is its compliance with various regulatory body rules, compliance with the Food and Drug Administration (FDA) regulations being chief among them. Equipment that requires a prescription to be dispensed must be tracked so that it can be recalled in the event that a recall is mandated by the FDA.
This means that your organization will need to keep track of the physical location of prescription equipment, whether that location is a specific patient's home, or your warehouse. Most HME software in use today has the capability to track the location of equipment by serial or asset number, however, if your software cannot perform this function, your company will need to design a computer database or paper-based system that will keep track of where each piece of equipment is at any given time. Accreditation surveyors will typically test your organization's ability to track equipment location by pulling random patient files, noting the current serial number or asset number of the equipment assigned to a patient, then providing the serial or asset number to a staff member and asking them to tell the surveyor the name of the patient to whom the equipment is currently being provided. Respiratory medications and oxygen are both prescription drugs so they are tracked by lot number, but the same principles and methods of evaluation apply.
Another area of focus by accreditation surveyors is an evaluation of the company's equipment routine maintenance records. In general, your company will need to make sure that it follows the recommendations of the manufacturer as to how equipment is maintained and at what frequency. If your company uses equipment that lacks specification from the manufacturer for routine maintenance procedures, a common sense maintenance protocol for that equipment should be developed and followed. In order to satisfy accreditation requirements, you will need to keep an electronic or paper-based record maintenance history on each item of equipment your company owns and provides to patients. If the item of equipment is eventually purchased by a patient the company is no longer responsible for ongoing maintenance, but it's still wise to retain the history of maintenance for the item for at least three years.
We have only scratched the surface of the requirements for successful accreditation, but these are the areas that should be addressed first and foremost by every HME provider who is considering seeking accreditation so that a significant history of compliance with accreditation standards can be shown during the eventual survey. Human resource issues, infection control standards, performance improvement activities, and company policy and procedures also factor heavily into the preparation for a successful accreditation survey. We will bring you more of tips for those areas in the next installment.
This article originally appeared in the April 2004 issue of HME Business.