4 Essential Steps for DMEPOS Accreditation Renewal

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Having an on-going plan for staying compliant with quality standards is the easiest and most efficient way to plan for a renewal visit. Yet, once the 3-year renewal visit is over, it is easy to take a hearty sigh of relief and say to yourself, “Ok, I don’t have to worry about this for three more years!”

Whether or not that sounds like you, we have some tips to help you prepare for your upcoming renewal. The earlier you work on preparation, the better.

  1. The most effective way for you to prepare for your next renewal is to review and act on your accreditation organization’s (AO’s) DMEPOS services renewal checklist. Doing this on an annual (or more frequent) basis will prepare you for an unscheduled on-site visit. Having things in order will make it much more likely you will have a stress-free on-site visit. Here are some of the most common issues we find deficient:
    • Maintain a quality improvement plan, updating the plan annually. This needs to be documented every year with new goals and objectives.
    • Annual policy and procedures review. Your P&P manual must be specific to your business and not a copy of a template. Many businesses do not review their policies annually and do not document that they have reviewed and/or revised them. Having updated P&P during the pandemic was critical. Be sure to document the changes you made to your P&P to deal with Covid and infection control.
    • Submission of patient satisfaction surveys to a database. Patient survey reports empower you to identify areas of weakness and target areas for improvement. They also provide you with significant data to share with potential referral sources. (see note below.)
    • Following manufacturer guidelines for use of disinfectants.  Disinfectants used to clean equipment must kill HIV, HEPB, and TB and need to be applied and used in accordance with manufacturer instructions. Make sure warehouse personnel are adhering to manufacturer guidelines.
    • Proper infection control adherence. Lack of glove use or inappropriate disposal of gloves.
    • Proper risk assessment. Review where you are vulnerable. Vulnerability can lead to liability.
    • High-tech HIPAA controls. Every business should create its own HIPAA risk assessment plan that includes avoidance and breaches.
  2. Look at any deficiencies you had in previous years. These will be reviewed by the on-site surveyor.
  3. Put yourself in the role of the on-site surveyor. Tour your facility on a regular basis and look for deficiencies. Ask your staff questions about what they are doing and how they are doing it. Go on unannounced site deliveries with your delivery personnel. Audit patient files at least quarterly.
  4. Have all documentation in one location so you will easily be able to share the information with the on-site surveyor. This includes:
    • Policy and procedure manuals
    • Licensing
    • Employee training checklists
    • Forms you have created for patients, wholesalers, product and service descriptions, organizational chart, P&L statements
    • HIPAA privacy notices
    • OSHA documentation
    • Employee files
    • Incident reports

Be prepared for your next renewal

While you are preparing for your upcoming on-site visit, take note of areas where improvement is needed and schedule times to address each area to ensure compliance in three more years.  A few things you might want to consider:

    • Assign employees to take leadership in overseeing deficient areas.
    • Pull out your calendar and schedule regular staff quality meetings and employee training. Document each instance.
    • Schedule your next review of the self-assessment checklist.
    • Let employees know that you will be performing unannounced tours of your facilities throughout each year.

Note: Not all AOs require submission of surveys. Entering patient satisfaction data into a database is a requirement in The Compliance Team’s standards. We believe that benchmarking your patient data against other organizations is critical to your quality improvement plan. To make this more convenient and cost-effective for our providers, we include access to our Patient Satisfaction Portal database at no additional cost.

Becoming an Exemplary Provider® starts here.

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