HQAA’s Quarterly Newsletter

to our peers, colleagues & Quality Champions

Full DMEPOS | Home Infusion / IV Compounding | Retail Pharmacy with DME | Medical Practice with DMEPOS | 3rd Party Billing | Vent Units

Vol. 5 Qtr. 2MAY 2014

The Office of the Inspector General (OIG) is responsible for protecting the integrity of HHS programs and operations by detecting and pre-

venting fraud, waste, and abuse and holding accountable those who do not meet program requirements or who violate Federal laws. The majority of the OIG resources are directed toward safeguarding the integrity of the Medicare and Medicaid programs and the health and

welfare of their beneficiaries. The OIG releases an annual Work Plan that summarizes the new and ongoing projects the OIG plans to pur-sue with respect to HHS programs and operations for that year.

Once the OIG identifies their areas of focus, audit contractors such as the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) contractors, Recovery Audit Contractors (RACs), and Zone Program Integrity Contractors (ZPICs) will often times follow suit and focus on similar topics or issues. What follows are details on some of the areas the OIG has listed as a focus for 2014. By having this knowledge, you can make a determination on the vulnerability of your business and then take the appropriate steps to identify your risk areas. Once you’ve identified areas of risk, you will be better suited to implement the appropriate controls or corrective action plans needed to minimize the possibility of an extensive pre-payment review (which can tie up your cash flow) or a postpayment review (which can result in an extrapolated overpayment). The OIG consistently compares the payments that Medicare makes for items and services against the allowables of other non-Medicare payers, such as private insurance companies and the Department of Veterans Affairs (VA), to identify potentially wasteful spending. In

previous years, the OIG found that Medicare overpays for various types of medical equipment. For 2014, the OIG will be reviewing Medicare’s fee schedule amounts for commode chairs, folding walkers, and transcutaneous electrical nerve stimulators (TENs units). Should the OIG determine that the amounts paid are in "gross deficient or excess amounts," CMS may replace the current fee sched-ule amounts with special payment limits they consider to be reason-able and equitable.

Power mobility devices are also a hot topic for the 2014 Work Plan. The OIG examines the lump-sum purchase versus the rental option to determine whether potential savings can be achieved by Medicare if certain power mobility devices (PMDs) are rented over a 13-month period rather than acquired through a lump-sum purchase. Atten-tion to supplier compliance with payment requirements of PMDs to determine whether such payments were in accordance with Medi-care requirements is also on the task list. The focus will be on wheth-er Medicare payments for PMD claims submitted by medical equip-ment suppliers are medically necessary and are supported in accordance with requirements at 42 CFR § 410.38.

Lastly, and maybe the most interesting of the three areas of PMD focus is the review of add-on payments for the face-to-face (F2F) examination to determine whether the F2F requirements were met. Medi-care requires that the treating physician conduct a F2F to determine the medical neces-sity and write the prescription. To receive compensation, the prescribing physician can bill for an evaluation and manage-ment (E/M) service and has the option of billing for an add-on payment for the sole purpose of documenting the need for the PMD. The OIG will be auditing these claims to ensure that the prescribing physician bills the correct E/M code as well as the correct code for the add-on payment. Without the add-on code, the resulting PMD claim will likely be determined to be unallowable.

The OIG will also review the reasonableness of Medicare payments compared to payments by other payers for parenteral nutrition

In This Issue From Mary's Desk 3

Recent Champions 4

This Month In ACT 6

Pharmacist's Dose 7

Regulatory Update 8

Ask the Surveyor 9

Ask the Coaches 10

The 2014 OIG Work Plan for DME SuppliersKelly Grahovac, Sr. ConsultantThe van Halem Group, LLC

Continued on next page

By having this knowledge, you can make a determination on the

vulnerability of your business and then take the appropriate

steps to identify your risk areas.

2

(infusion). Previous OIG work found that Medicare allowances for parenteral nutrition averaged 45 percent higher than Medicaid prices, 78 percent higher than prices available to Medicare risk-contract health maintenance organizations (HMO), and 11 times higher than some manufacturers’ contract prices. Suppliers saw the start of competitive bidding in 2013 in the ma-jority of regions, with the initiation of the national mail order pro-gram. The OIG will perform mandatory reviews for both diabetes testing supplies, to determine the market share of different types of diabetic testing strips, and for medical equipment items and services, to review the process CMS used to conduct competitive bidding and to make subsequent pricing determinations. Federal Law requires the OIG to conduct post-award audits and to assess processes.

The OIG will take a dual approach in reviewing diabetic supplies. From the payment perspective, the OIG will review payments for home blood glucose test strips and lancet supplies to also de-termine if suppliers comply with Federal requirements, specifi-cally the use of KX or KS modifiers, to identify when a patient is or is not treated with insulin and results in varying reimbursement amounts. The OIG will also review Medicare’s claims processing edits to determine whether they are effective in preventing inap-propriate payments. Prior OIG work found that inappropriate pay-ments were made to multiple medical equipment suppliers for test strips and lancets dispensed to the same beneficiaries with overlap-ping service dates.

The OIG will review supplier compliance with payment require-ments for lower limb prosthetics and for nebulizer machines and related drugs to determine whether claims are medically neces-sary and that the requirements were met. For lower limb prosthet-ics, a national review identified 267 suppliers that had questionable

The 2014 OIG Work Plan - Continued from previous page billing to include frequently submitted claims that did not meet certain Medicare requirements, were for beneficiaries with no claims from their referring physicians, and had other questionable billing characteristics (e.g., billing for lower limb prostheses for a high percentage of beneficiaries with no history of amputations or missing limbs). Regarding nebulizer machines and related drugs, prior OIG work found that suppliers were overpaid approximately $46 million for inhalation drugs used with nebulizer machines.

Also on the OIG 2014 plan is that there will be a review of claims for frequently replaced medical equipment supplies to deter-mine whether the medical necessity, frequency, and other Medi-care requirements are met. Prior OIG work found that suppliers automatically shipped continuous positive airway pressure (C-PAP) systems and respiratory-assist device (RAD) supplies when no physician orders for refills were in effect. Per the IOM 100-08, Ch. 4, Section 4.26.1, Contact with the beneficiary or designee re-garding refills should take place no sooner than approximately 7 days prior to the delivery/shipping date. For subsequent deliver-ies of refills, the supplier should deliver the DMEPOS product no sooner than approximately 5 days prior to the end of usage for the current product. The supplier must not automatically dispense a quantity of supplies on a predetermined regular basis, even if the beneficiary has "authorized" this in advance.

As always, being compliant in your billing practices to include hav-ing the appropriate documentation (as defined in the LCD) can result in reduced scrutiny of your business by outside entities, par-ticularly with an audit. Be proactive in your processes, not only by ensuring that your documentation meets all policy requirements, but also through awareness of the services being reviewed by the OIG and other audit bodies. This proactive approach allows you to ensure your beneficiary records are complete and that your office staff is trained appropriately.

* * * * *

Sarah and Kit from ECS Billing North stopped by the HQAA booth at the Healthcare Billing Managers Association to say hello! As they are new members to the HBMA group, Curt and Mary were pleased to see them.

3

From Mary's DeskMary Nicholas, MHAPresident, CEO

Quality Works!

Here’s Our Latest News - What’s Yours?

We hope you are enjoying your issues of Champion Chat as much as we enjoy providing them to you. Help us stay in touch with what’s happening in your world by keeping us up-to-date. We rely on you to suggest stories, submit questions to our team of experts and give us feedback on the items and articles you are reading. We need you, our industry colleagues and accredited providers, to keep us in your “loop." If you, a co-worker, supervisor or owner of your company has been recognized in some way, or has done an outstanding job of demonstrating Champion behavior, submit your nominations for HQAA Champions in the News to info@hqaa.org so that we can share your pride in mak-ing a difference in your customers lives, your community, or in the industry. We appreciate the questions you’ve sent to Ask the Surveyor and Ask the Coaches and hope the questions and answers we’ve featured have been helpful.

Your involvement helps us stay informed and in touch. Keep those emails coming!

I’m sure that most of us have seen at least one episode of “Extreme Home Makeover.” The fascination for me, as I’m sure with many, is how an entire home and homestead can be created within such a short period of time. Well, I found an answer today while read-ing my April 2014 issue of Quality Progress, the quality journal for the American Society for Quality. The article, entitled, “A Place to Call Home," thoroughly described a particular home builder’s quality management practices and culture of innovation. I found it truly amazing how the contractor, Veridian Homes, used no less than 27 different quality-related processes and techniques to ac-complish a finished home within 106 hours.

The point of my bringing this to your attention is to reinforce that managing quality and the associated techniques can actually work. It worked to perfection in creating a home, what’s not to say that it can work in our workplaces as well? Nothing. Managing quality in a way that works for us all is, and always will be, how we should forge into the future, no matter what it brings. This contractor re-duced the average time for construction phases from 255 hours to just 28! That’s approximately a 90% reduction of time for many of the primary build-outs in constructing a home. Just imagine if we created such efficiencies!

One (of the 27) techniques identified is called 5S Lean. In famil-iarizing myself with that specific technique, I could really identify with the framework and thought I would pass it along in this col-umn. Please realize that books and volumes have been written about this technique. I am briefly summarizing it in order to hope-fully initiate curiosity about it.

5S Lean is a methodology of 5 “S” words describing processes to or-ganize the workplace, reveal problems, and sustain improvements. It originated in Japan and has been translated and used in the U.S. by many large and major companies. In some circles, there are 6 S’s and even 7 S’s, so I offer them all for your review:

1. Sort: This keyword indicates that in order to have an efficient workplace, the workplace and all workstations need to be or-ganized. This method says that only the tools to do the job should be in the work area, all unnecessary items should be eliminated.

2. Systemize: This keyword indicates that everything has a place and should be kept in that place. Always. Knowing where to find the tools to do the job eliminates unproductive time and efforts.

GET CONNECTED

3. Sanitize: Scrubbing, washing, sweeping, and overall cleanli-ness should be consistent and also used as a way to inspect the workplace. Cleanliness is a way to reveal problems.

4. Standardize: To standardize is to create routines to maintain the first three S’s. Standardization is also a way to build-in preventative maintenance, not only with the physical building, but with tasks as well.

5. Sustain: Sustaining occurs when all four of the above become a way of life in the workplace. When everyone keeps their workstations and workplace organized, clean, and routinely managed, issues that arise can be dealt with within this meth-od.

6. Safety: An add-on for many, which places employee safety as an integral focus and is partnered with a clean, organized workplace.

7. Security: Another add-on that some include, which undoubt-edly has a focus on securing the environment from internet threats and physical harm.

Use of the above techniques is a part of a quality system in an or-ganization that focuses on results and the processes that produce results. I know that none of us have to build a home in three days, but I do know that quality works and can work for us as we con-tinue to build our futures.

* * * * *

HQAARecently Accredited Quality Champions

4

We look forward to listing your company as one of our Quarterly Champions! Come join our family!

A & W Home Medical Equipment Inc.

A Plus Medical Equipment & Supply, Inc

ABC Medical, LLC

ACTS RESPIRATORY & MEDICAL EQUIPMENT INC.

Advanced Medical Equipment, INC.

Advanced Pharmacy Inc.

Advantage Healthcare of Charleston, LLC

Aeratech Home Medical, LLC

All Saints Home Medical, LLC

ARIANNA MEDICAL PHARMACY INC.

Asante Community Services, LLC

Aspinwall Chiropractic Clinic,LLC

B&G HARVEST MEDICAL SUPPLY, LLC

Badger Pharmacy, LLC

Bates Drug Stores, Inc.

Bauman Chiropractic Clinic of Northwest Florida, PA

BEGGS PHARMACY, INC.

Best Aid Medical Supplies

Better Lives LLC

BrightChoice Medical, Inc.

C J Pharmacy Services, LLC

Caldwell and Wilhoit, Inc

Cammack`s Pharmacies Inc.

Central Kansas Respiratory Services LLC

Chiropractic Associates, Inc.

Columbia Medical Sport & Spine LLC

Complete Care Solutions, Inc

CompreCare Services, Inc.

Detroit Oxygen & Medical Equipment Co.

Eclipse Medical, LLC

Eventa LLC

Family Health Physical Medicine LLC

Forest Hills Pharmacy, Inc.

Foster Drug Company Inc.

Genesee Home Healthcare Products, Inc.

Glasgow Chiropractic LLC

Grace Medical, Inc.

Grubb's Pharmacy of DC Inc.

GWR Medical, Inc

H&H Integrative Pharmacy

Harbor Oxygen of Traverse City, LLC

Healing Air, Inc.

Healing Hearts Home Medical Supply

Home Health Warehouse

Hometown Physical Medicine PLLC

HUBBARD PHARMACY, LLC

Integrative Health of Orlando LLC

J & J Home Health Agency Inc.,

Please join us in congratulating these recently accredited providers.

Jajco Inc

Jefferson Pharmacy, Inc.

KINGWOOD PHARMACY LLC

Lake County Physical Medicine, S.C.

Legacy Oxygen & Home Care Equipment, LLC

Lemon Grove Medical Supplies, Inc

Life Guard Inc.

Matrix Mobility & Healthcare Products, LLC

MCCOB Styles

MCS Enterprises, Inc

Melancon Medical Equipment & Supplies, LLC

Midland Sleep Central LLC

Midlands Physical Medicine

MLM Pharmacy, Inc.

Morton-Wuebbels Pharmacy, Inc.

My Ideal Care, LLC

Nebraska Scooter Mart LLC

Otway Pharmacy Partners, Inc.

Park Lake Physical Medicine, LLC

Performance Care Group Inc.

Performance Respiratory, Inc.

Physical Healthcare of Jacksonville Inc

Physician Support Associates

Plymouth Towne Care Pharmacy Inc.

Power Chairs and Scooter Store Medical Supply, LLC

Powhatan Pharmacy, Inc.

Preferred Medical Center

Prescription Shop, Inc

R.W.K. Inc

Rehab Solutions Specialists Inc

Rhodes And Tetmeyer Properties, LLC

Rick's Medical Supply, Inc.

Riverside Medical, Inc.

Rocky Mountain Medical Equipment, Inc

San Angelo Health Care LLC

Scott Medical Equipment LLC

Simpson Chiropractic Pain & Wellness Center, PA

Stockton Finance

Sunnyside Community Hospital Association

Super Pharmacy LLC

Tri-State, Inc.

University of Iowa Community Medical Services, Inc.

Vasocare LLC

Vitality Spine Center, Inc.

VLC Drug Inc.

Wellness Strategies LLC

William Jeremy Harvey

Woodward CJS Pharmacy, Inc.

Your DME Company

Zylstra Medical Supply, Inc

5

Upcoming Topics

MAY

Emergency - Disaster

Preparedness

JUNEInfection Control

& Safety

JULYCompliance

ACT (Accreditation Continuation Toolkit) is the program offered to HQAA accredited providers after their successful accreditation to assist them in maintaining and updating their high quality standards and accreditation requirements on an ongoing, on-line basis so that accreditation renewal is smooth and seamless. It is the only such product offered to assist with accreditation renewal in the industry. AMPT (Accreditation Maintenance Program Toolkit) is its counterpart for all accredited providers. AMPT is not for HQAA customers, but for all others that understand the importance of maintaining accreditation standards.Each month, providers enrolled in ACT or AMPT work with a “bite-sized” component of standards to ensure that they are reviewing and updating their processes as needed. By addressing accreditation compliance requirements in small, "bite-sized” components, last-minute renewal work is eliminated, and what can be extensive work is accomplished in efficient, incremental steps. Featured monthly topics assist providers in conducting audits and updating information. Providers who subscribe to ACT receive the plans, tools, and access to experts in one easy-to-use website, saving both time and money.In this issue we are highlighting the ACT/AMPT topics for May, June, and July, and listing some of the questions posed for subscribers to review to ensure that they are meeting their accreditation standard requirements.

May - Emergency - Disaster Preparedness What is your organization’s definition of an emergency or a disaster? What alternative arrangements have been made with alternate providers in the event that you can’t service your customers? What information do you provide to your clients regarding disaster and emergency preparedness?

June- Infection Control & Safety Are your new staff members always oriented to infection control and safety issues? What is your process for separating clean items from dirty or contaminated items? Are your vehicles up-to-date regarding safety equipment and cleanliness?

July- Compliance Your compliance program must be much more comprehensive than when you were first accredited. Ensure that your program is complete and effective. Are you auditing your claims to ensure that you are billing correctly? Using the appropriate modifiers when necessary? Are you collecting co-payments appropriately? If you identify an overpayment, is it refunded promptly?

This Month in

Only HQAA offers on-going service to maintain the accreditation you've worked so hard to achieve. For more information about ACT or AMPT, contact Gabriel Nicholas: gabe.nicholas@hqaa.org or 866.490.7980

I'm thrilled with teaming up with HQAA. It has truly helped me build us into a higher quality business. Your Surveyors are professionals with a wealth of experience and knowledge that is always helpful. Our Quality Controller uses ACT daily to ensure the quality process continues every month, not just before the next survey.

Breath of Life Home Medical Equipment and Respiratory Services Inc. Westfield, IN

Here’s what a current customer has to say about HQAA:

See more testimonials on the HQAA YouTube page by clicking here.

6

7

I recently attended the National Home Infusion Association’s (NHIA) Annual Conference where I moderated some round table discussions on the topic of “The Ambiguous Mandates for Sterile Compounding: Putting the Puzzle Together Without All of the Pieces.” Like most years, I learned the most from my colleagues who are in the field struggling to take care of their customers while meeting all of the requisite regulations.

One of our biggest challenges today is knowing what those requisite regulations actually are that we are required to meet. The Drug Quality and Security Act (DQSA), signed into law by President Obama, substantively altered the Food, Drug and Cosmetic Act of 1938 (FD&C). Section 503A of the FD&C is seen by many as “protecting” traditional drug compounding by pharmacies that have a valid prescription in hand which is signed by an authorized prescriber. But 503(a) may also give the FDA far more oversight that it has previously had in regulating traditional pharmacy compounding. If you are not familiar with 503(a) yet, I would encourage you to read the FDA’s Draft Guidance docu-ment. (FDA 503 Guidance link: http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegu-latoryInformation/Guidances/UCM377052.pdf)

When reading the Draft Guidance, take note of the logic with which the FDA intends to undertake enforcement. They say they intend to leave pharmacies alone unless they find them to be out of com-pliance with other sections of FD&C, particularly Sections 501(a)(1) and (a)(2)(A). If your condi-tions are sufficiently unsanitary, the FDA states that “individuals and firms may be subject to a warn-ing letter, seizure of product, injunction, and/or criminal prosecution.” Several pharmacies have received such warning letters and each individual case is working its way through the federal system.Another vital cog in DQSA is reflected in Section 503B of the FD&C, which establishes a new cat-egory of provider called, “outsourcing facilities.” An outsourcing facility voluntarily registers with the FDA, pays the associated fees that help cover the cost of an FDA inspection, and stipulates that it will compound products under Current Good Manufacturing Practices (CGMP).

Many large compounding pharmacies may have had the expectation that the FDA would create a sort of CGMP “light” so that pharmacies could improve their current processes, but not bring them up to the level of CGMP compliance that would be required of manufacturing organizations such as Eli Lilly, Pfizer, or Merck. If anyone did believe that, I fear they may be in for disappointment. The FDA is not in a position to allow any half-measures in CGMP or the sector would be flooded with manu-facturers seeking less regulation. I believe that at the end of this reshaping of pharmacy sterile com-pounding, CGMP will still mean exactly what it says and FDA will enforce it just as they always have.

Unfortunately, as I write this, we cannot read the regulations that will determine so much of how our new practices will look. The Secretary of Health and Human Services has not promulgated those regulations and will not publish them until later this year.

In the aftermath of the DQSA, many states are revising their regulations right now. I encourage all readers to stay in touch their state boards of pharmacy to know what they have in store for you relative to your state regulations. Speaking at the conference, NHIA’s legal counsel, Alan Parver, quipped, “If you’re not at the table, you may find yourself on the menu.”

Pharmacist's DoseThe

Willis C. Triplett oversees HQAA's home infusion IV compounding and pharmacy programs. He has extensive experience in all aspects of home infusion therapy as an owner, senior leader, and consultant.

Willis C. Triplett, PharmD., Infusion Specialist

Shifting Regulatory Mandates

HQAA

On the Road

Come visit us at:

May

PAMS Annual Convention

5/1-5/2 State College, PA

GAMES Spring Conference

5/1-5/2 Savannah, GA

Great Lakes HME

Association Inaugural

Conference5/20-5/21

Tinley Park, IL

June

Heartland Conference

6/9-6/12Waterloo, IA

8

Regulatory UpdateMary Ellen Conway, PresidentCapital Healthcare Group

Maybe you were busy in February managing the chaos of your daily operations, or another weather crisis, and you missed the lat-est from CMS. Their announcement, titled “Medicare Program; Methodology for Adjusting Payment Amounts for Certain Du-rable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) using Information from Competitive Bidding Pro-grams” was published on February 24th in the Federal Register and caught everyone by surprise. The notification states that the agency seeks comments on

1. Developing a methodology to adjust payment rates in non-bid areas based on bid rates; and

2. Bundling payments for certain DME, including complex rehab and enteral nutrition. CMS states that they want to “simplify” payment rules under competitive bidding for enteral nutrition by creating one monthly payment to include all equipment, supplies and service.

Industry experts were not just surprised by this published an-nouncement, they were shocked. This yet another is a game-chang-er for DMEPOS Suppliers that threatens ongoing successful opera-tions.

Expanding the Bidding Program

The Affordable Care Act requires that CMS either expand the bid program or apply bid rates to non-bid areas by 2016. From the beginning, industry experts understood that CMS would simply expand the program by applying the bid rates nationally in 2016. This proposed rule is a radical departure from current payment methodology as we are learning this entirely new direction CMS wants to take.

CMS accepts no accountability for the underlying problems with the existing program, including the lack of transparency and non-binding bids. The program was poorly designed and implemented in a disorganized fashion. As an example of one flaw, bids in Round 2 from unlicensed bidders were included in calculating the single payment amount (SPA) in the area and while CMS may have ex-cluded those providers from participation, they never re-calculated the bids without including those who were not qualified to bid. Additionally, applying the current Round 2 payment rates from the bidding program to areas outside of competitive bidding areas (CBAs) is not economically sound, and the lack of transparency in awarding contracts continues to undermine the credibility of the process.

The Latest Reason for Our Weekly Panic Attack:

CMS Advance Notice of Proposed Rulemaking (ANPRM)

Additionally, the costs of doing business in rural areas, and others such as Alaska, Hawaii, and the U.S. territories are unique to those areas and cannot possibly be accounted for by the bidding program as it’s currently designed.

Bundled Monthly Payment

CMS wants to attempt to create a bundled monthly rental payment to replace the current rental and routinely purchased payment cat-egories. The proposal is to include all equipment, supplies, and ser-vice for enteral products in just one payment.

This is not just a nightmare, but a feasibility issue. There are too many variables when it comes to providing enteral nutrition to pa-tients - there is no “standard” patient. Patients receive enteral nutri-tion through a variety of means, which may or may not include a pump. The costs of individual enteral formulas and the amount of formula used by the patient on a daily basis run the gamut as well.

AAHomecare responded immediately to this announcement with a letter to CMS Director Marilyn Tavener. They stated:

“We recognize that competitive bidding can lower payment amounts, but we believe there is no credible evidence that the program has in fact met its goal of protecting the qual-ity of equipment and services that beneficiaries receive. The program has not been evaluated to determine its effects on beneficiary access.”

“The ANPRM states CMS’ intent to establish one bundled monthly rental payment for all the DME and enteral equip-ment and related supplies a beneficiary would need during a period of medical necessity. The bundled monthly rental payment would replace the rental and routinely purchased payment categories established by Congress under the fee schedules. We are concerned by this proposal. AAHomecare believes CMS lacks data that could be used to align an indi-vidual’s medical necessity for equipment and services to the Medicare payment for those items and services. In addition, we think this type of bundling would be so complex that it would be premature to implement this methodology under the DMEPOS benefit without a comprehensive analysis of the costs to furnish equipment to a chronically ill patient with a progressive condition.”

The consequences of these proposed rules will impact every Medi-care beneficiary, regardless of where they live. It’s too early to know where this is going, so stay tuned and stay in touch with your state and national associations so that you can lobby your congressional representatives, especially when they are in their home offices, and tell them what CMS’ proposed rules will do to your livelihood. It’s hard to believe that we will ever again have a simple and reasonable Medicare reimbursement rate for DME, much less a simple process for providing it to beneficiaries.

Mary Ellen Conway, RN, BSN, is a nurse health care consultant with over 25 years expertise in management throughout the health care continuum, and the President of Capital Healthcare Group.

9

To sign up to receive Champion Chat or to have copies sent

directly to additional staff members, contact us at 866-909-HQAA

and tell us who to add to our mailing list

Submit your questions by clicking “Ask the Surveyor”

your questions answered...Ask the SurveyorJim Moyer,Director of Survey Quality

HQAA recently evaluated the percentage of repeat deficiencies that surveyors have cited during triennial surveys. Repeat deficiencies are those that have been cited on the previous survey and are now cited again three years later. At the time of the first survey, orga-nizations write a Plan of Correction that is reviewed before it is approved. These Plans of Correction assure HQAA that the stan-dard will be corrected and maintained ongoing. Our data review indicated that the frequency is high enough to now put additional focus on supporting improvement with our customers.

With this article, I will note some of the standards that have shown the highest levels of repeated citations with renewal surveys. For a more in depth discussion for each, please refer to the blog article link can be found at the end of this article.

Of the deficiencies noted, it is worth mentioning that three of them are within the Human Resources section of standards.

1.) Competency Program: The primary deficiencies found during on-site surveys are that the organization has not documented that personnel providing direct patient care have had competency assessments at hire and annually. These evaluations must include direct observa-tion.

2.) Personnel Files:There are various reasons that surveyors are finding that orga-nizations are not meeting this standard. Some include:• Not having documented evidence of the required annual

education on-file• Current I-9 forms (May 2013 version for those hired after)

are incomplete- either because the documentation is not signed by the organization representative or the form is missing

• Annual performance appraisals are incomplete per com-pany policy

• Hepatitis vaccination or declination is not evidenced for staff per company policy

• Files for those hired within the last three years do not in-clude two completed reference checks

• Evidence of interview is missing• Current job descriptions are missing and/or unsigned

Worth Noting...

3.) Annual Education Program:The surveyors are finding that many organizations are non-compliant with the required topics for the annual six (6) hours of education for all staff. The four required education oppor-tunities are: • Infectioncontrolandbloodbornepathogens• OSHAandsafetyissuesincludingfiresafety• Disasterpreparedness• HIPAAprivacyandsecurity

4.) Maintaining a Clean, Safe and Organized Work Environ-ment:

The most common issues found during the triennial site survey include fire extinguishers not inspected and current; first aid supplies and eye wash stations missing or expired; eye wash not located near the cleaning and disinfecting area; unlabeled or improperly labeled secondary containers of chemicals; equip-ment cleaning and/or storage areas unclean and/or cluttered; and exit strategies not posted.

5.) Quality/Performance Improvement Program:Surveyors are observing that organizations are not adhering to, and/or documenting evidence of the Medicare required indica-tors of patient satisfaction, complaints regarding products and services, billing and coding errors, timely response to custom-ers regarding problems, issues or concerns, and adverse events. Medicare requires companies to design, monitor and measure their quality improvement for these indicators. Most organiza-tions may show evidence of collecting information from their patient surveys and the note that they have had no adverse events, but there is no documented proof of the other required items. This leads to a citation for incomplete reporting require-ments.

The best way to prevent repeat deficiencies cited is, of course, to ensure that all standards are maintained in the 3-year period be-tween surveys. We realize that sometimes it feels like trying to build a house on shifting sand, however, there are many tools, tips, forms, checklists and “help” articles available to you. Ensure that responsibilities are assigned and that completion is a requirement. HQAA recently added the ability for all customers who are renew-ing to print off their past survey report for use in reviewing results from that survey. Use that report as a guide for an improved survey in the future.

* * * * *

10

Ask the CoachesI am new to the company and want to review the last survey report before our upcoming survey. How can I obtain it? A: HQAA has recently redesigned the view in the workroom. With the redesign, there is the addition of a link that you can click on to view your previous survey report on the Table of Contents page. • If you are in the renewal process, you would simply log into

the workroom. You will see the link "Click here for last Survey Report" on the Table of Contents page.

• If you are currently an ACT Member, you would log in to ACT and then click on . . . . . and then . . . . . This tab will take you to your Table of Contents page where you will see the link "Click here for last Survey Report."

Q: Is there a way to review the policies we have sub-mitted within the workroom? A: To review the information, you would enter the standard as though you were going to upload a policy or form. To the left of a gold HQAA checkmark icon , you will see the “Sent” box . By clicking on the blue check mark icon, you will open the infor-mation you previously submitted.

Q: How do I know that a document or form I have submit-ted has met the re-quirement for that standard?A: To see if your submis-sion has met the requirement, navigate through the workroom to the standard page as if you were going to upload documentation. To the right of each required document, you will see three boxes; Rec’d, In Rev, Filed. When you see a blue check mark in the ‘filed” box, you know that the information has been accepted.

Q: I submitted the wrong policy for the standard, or clicked the "re-use doc" option by accident. Am I able to resubmit a new document? A: Yes. Follow the upload process as you did with the initial sub-mission. Click on the little gold ball, "browse" or "choose file" to upload, then click on the upload tab. The new document will over-write the previous submission.

866.909.4722

Courage.It takes courage to begin any new journey – including accreditation. And in every quality champion you’ll find a can-do attitude and a courageous spirit. HQAA accreditation coaches build your courage with advice, encouragement and feedback. Together, we’ll tackle today’s challenges and train for tomorrow’s hurdles. At HQAA, we build quality champions one brick at a time.

HOW DO YOU BUILD A QUALITY CHAMPION?

See how at HQAA.org/buildingchampions.