Dec 6, 2021

Is 2022 the year your clinic is up for your accreditation renewal on-site visit? Will you be prepared when the surveyor shows up unannounced? Have you maintained evidence of compliance over the last three years and throughout the pandemic?

If you answered no to any of these questions, then you need to follow the guidance below to ensure you have a positive experience during your next renewal site visit. Here are some helpful tips for renewal success:

  1. Remember that compliance is a team sport. Involve your staff so everyone is looking out for possible issues.
  2. Have the team and all new hires watch the Renewal webinar on our website at www.thecomplianceteam.org. Log in and go to webinars to view it.
  3. Remember that, to comply with Emergency Preparedness, you must write an analysis of an event, an exercise, or tabletop. Although the pandemic is an ongoing event, you must document it properly for it to qualify. The elements required can be found on the CMS AAR. They include:
    • Provide a brief overview of the exercise, event or table-top.
    • Enter the capabilities tested by the exercise, event or table-top.
    • Enter the major strengths identified.
    • Enter areas for improvement identified during the exercise, including recommendations.
    • Describe the overall exercise as successful or unsuccessful, and briefly state the areas in which subsequent exercises should focus.
    • Determine what can be used after an exercise, event or table-top.
    • Include a log in sheet with signatures to show that you reviewed the results with your staff.
  4. Don’t forget to update policies to reflect any changes to protocols or regulatory requirements.
  5. The Compliance Team’s RHC checklist is a great tool to utilize. Conduct a mock survey with staff to identify any compliance issues that need to be addressed prior to your renewal site visit.
  6. Don’t worry . . . be prepared!

Call the The Compliance Team home office if you have concerns or questions or need additional information. Ask for an RHC advisor to assist you.