Conducting a Pre-survey for Accreditation

By Ron Turzy, VP of Complex Rehab, U.S. Rehab

The words “We’re getting ready for our accreditation survey,” usually strikes fear into many health care providers. Often times, it can feel so overwhelming and stressful that it paralyzes the company for weeks, sometimes months.

To help prepare and reduce that unnecessary anxiety, I suggest conducting your own mock pre-survey.   If you have several branches, the surveyor will start at the headquarter location and then will want to travel to two or three other sites, pending proximity. Also, be aware the actual surveyor WILL travel locally with ATPs and service technicians, so be prepared to have them travel with your best!

To conduct the mock pre-survey, select a person in your company who has management oversight and was involved in the previous survey. That person should have a basic understanding of all functional departments: sales/marketing, operations, warehouse, customer service, purchasing/billing, human resources, and accounting/finance. Owners need to be self-accountable (and please do not run and hide the day of the survey; yes, that actually has happened).

Use the previous survey as a guide. That will have the outline of actionable items and results. Take note of the deficiencies – developmental needs of the company. Those will be key areas for the surveyor to likely dig into again.

Make sure you have the basics down and your policy and procedure manual is up to date. Here’s a list of common areas of focus:

  • Performance improvement/measurement summary reports, 12 months of data
  • Infection control summary reports, 12 months of data
  • Infection control plan
  • Emergency management plan and annual evaluation (annual evaluation may not be applicable for the initial survey)
  • Name and phone number of key contact person who can assist surveyors in patient visits or observation of service delivery
  • A copy of your organizational chart and a list of personnel and their roles (including contract staff)
  • List of all sites, branches, and services if applicable
  • Measures of success (MOS) identified in the plan of action from the periodic performance review (not applicable for initial survey)
  • List of scheduled home visits for the duration of the survey, including type of service, disciplines, diagnosis, date of admission, and location (home health, personal care and support services, pharmacy, home medical equipment/DMEPOS, hospice)
  • List of scheduled deliveries, mail orders, or planned walk-in business for the days of the survey and from specific points in time as delineated by the surveyor (home medical equipment/DMEPOS, pharmacy). The list should include the type of medication/therapy, durable medical equipment, prosthetics or orthotics being supplied/delivered. Supplier’s date of first encounter/admission, and address IF delivery is part of the service.

For more information, feel free to reach out to me at [email protected]m or 844-295-0264.