Preparing for Site Accreditation Survey Part 2: Mock Survey

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

Last month, I covered what areas should be included on a mock survey. Below is a write-up from an actual mock survey with items that need to be corrected. Date and have reasonable timeframes for each item to be corrected. Ownership should assign the person responsible for rectifying deficiencies and a due date.

Pre-Survey Results, Branch Name, Date

  • Comply with hepatitis B policy (applicable staff only).
  • Comply with tuberculosis policy (applicable staff only).
  • Job descriptions need to be in P&P manual and shared with staff, M.L. notified.
  • Remove staff testing results from P&P manual, file separately.
  • Insert most recent Employee Handbook in pocket of P&P manual.
  • Information binder absent of all required documentation; complete this requirement PIP Meeting Notes, Revised C/S surveys, Revised Repair Service Surveys, Medicare Denial info., PIP Project data, etc.
  • Consider better organization of equipment in the middle of the showroom.
  • Handwashing policy posted at all sinks in office lavatories and warehouse, copy Handwashing Guidelines from Chapter Three and post (see attachment in email).
  • Need antiseptic/anti-viral handwashing soap and paper towels at all sinks to accommodate I/C control standards.
  • Signage in warehouse listing major areas of equipment storage and function of area, e.g., Repair Area, Battery storage area, Rentals, etc.
  • MSDS Binder needs to be organized alphabetically by product for quick reference in case of an emergency.
  • Forklift, mops, bucket, sink area needs to be designated as a dirty area and red tape applied to the floor.
  • Verify all fire extinguishers are charged and current with local fire department.
  • Conduct training for the use of fire extinguishers for all staff.
  • Insure all staff knows the exit routes available in case of a fire.
  • Training manuals for forklift, disc sander, grinder, drill press and other power equipment need to be available as well as how the operators are trained on the safe and proper use of the equipment.
  • Strongly suggest that all cushions be cleaned and stored in their original boxes, when possible.
  • Waterproof gloves, goggles, and poncho to be used when cleaning equipment using the power washer.
  • CHANGE the tags to Red=Dirty and Green= Clean.
  • A sign on the wall in the corridor from the main entrance to the warehouse indicating the route to take dirty equipment from the office to the warehouse for in-house repair work.
  • Organize battery charging area with signage and keep all batteries OFF the floor.
  • Remove heavy PWCs from the top shelves! Use a chain to secure equipment from falling forward off the top shelves in the warehouse.
  • Clean junk out of black filing cabinets in the warehouse located by the water heater
  • Four client files examined found only one Client Profile Sheet and that was not signed by the client.
  • Hand out Repair Surveys on all repair calls; it’s up to the client if they will fill them out.
  • Include Fall Prevention guidelines in Welcome packet (it’s attached to this email).
  • UPDATE Welcome Packet and Delivery Packet to most recent revisions.
  • Have meeting minutes available for inspection by the surveyor.
  • Use Complaint/Commendation form and store them in a binder to be kept in the manager’s office. Insure that written documentation shows resolution of all complaints.
  • Insure the use of cargo straps to secure equipment during transport.
  • Insure that all I/C and supplies from the vehicle supply checklist are in all company vans.
  • Use a “tarp” to segregate the dirty equipment from the clean equipment during transport.
  • Consider heavy plastic “visqueen barrier” to cover the shelves in the warehouse.
  • Keep warehouse floor clean by sweeping as needed.
  • Insure that main entrance is clear of debris and snow for safety reasons.
  • Continue to be conscience of client file security.
  • Should client files leave the building, insure the client file checkout log is used,
  • Document how equipment is cleaned and maintained; see policy Chapter Six.
  • Complete Vehicle Safety Inspection checklist monthly and keep them on file.

These are some of the important standards that a surveyor may be focusing on:

PI.1.10 The organization collects data to monitor its performance and follows a process to evaluate the information.

LD.1.30 The organization complies with applicable law and regulation.

HR.2.10 The organization provides initial orientation.

HR.3.10 Staff competence to perform job responsibilities is assessed, demonstrated, and maintained.

LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

NPSG.09.02.01 The organization implements a fall reduction program that includes an evaluation of the effectiveness of the program.

HR.01.06.01 Staff are competent to perform their responsibilities.

HR.01.02.05 The organization verifies staff qualifications.

IC.01.03.01 The organization identifies risks for acquiring and spreading infections.

EQ.01.03.01 The organization maintains tests and inspects the equipment it provides to clients.

RC.01.01.01 The organization maintains complete and accurate client records.

I hope this information helps when the time comes for your next accreditation survey. In fact, running your organization by your Policies and Procedures by having quarterly meetings on effectiveness and having up-to-date measurables is the way to go. One such QA tool is our Functional Mobility Outcomes (FMA) program. Using that tool and gathering data will show your accreditation surveyor that you are an A+ organization.

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