see page 4 urveyor - accreditation commission for health care spring 2005.pdf · 2006-02-27 ·...

501 3(C) Nonprofit Organization

URVEYORSSpring 2005 Volume 14, No. 1

INSIDEUniversity of Iowa CommunityHomecare Renews

Community HomeCare, an affiliate of the Universityof Iowa Health Care, has renewed its accreditationwith ACHC. UI Community HomeCare, a full-service medical equipment and infusion servicesprovider, offers patients and families convenienceand peace of mind. See 5

ACHC Applies for MedicareDeemed Status

Caldwell County Hospice Caldwell County Hospice was established in 1982by a group of community leaders to provide holisticcare to terminally ill patients. CCH began in a borrowed Sunday school room atthe First Presbyterian Church in Lenoir, North Caro-lina, with one paid staff member and a handful of vol-unteers.

See Page 4

Raleigh, N.C. – The Accreditation Commission for HealthCare, Inc. (ACHC) is pleased to announce that it has sub-mitted application for Medicare Deemed status for home healthand hospice to the Center for Medicare and Medicaid Ser-vices (CMS). ACHC’s strategic plans have included attaining certifica-tion to ISO 9001:2000 in 2004 and Medicare Deemed sta-tus for home health and hospice by the end of 2005. ACHC believes that achieving these two milestones greatlystrengthens its marketing position among other national ac-crediting organizations. In April 2004 ACHC became thefirst healthcare accreditor in the world to be certified to ISOstandards. ACHC has gained respect and recognition as the accred-iting organization uniquely committed to support those di-rectly responsible for healthcare delivery. It has adopted aparticipatory approach to standards development that ac-tively solicits the input of those providers and organizationsmost knowledgeable about current approaches to care. The result has been the development and dissemination ofstandards that are high in quality, practical in application, andeffective in assuring optimum care delivery to the patient. Theentire accreditation process is designed to positively impactthe way care is delivered through an approach that is col-laborative, educational, and genuinely patient focused.

Several Chartwell locations have turned to ACHC foraccreditation in the past year. The most recent location wasChartwell Pennsylvania. Chartwell Pennsylvania is a part-nership between Chartwell Home Therapies and the Uni-versity of Pittsburgh Medical Center, St. Margaret’s Me-morial Hospital, Passavant Hospital, The Washington Hos-pital, Children’s Hospital of Pittsburgh and Jefferson Re-gional Medical Center. Services include infusion therapy,nutritional services, pediatric services and skilled infusionnursing. Chartwell Diversified Services, Inc. is one of the nation’sleading providers of healthcare services in the home setting.Chartwell provides home health care services to nearly55,000 patients a year in 18 states with 22 service loca-tions. Services include infusion therapy, respiratory therapy/CME, attendant care and health care management services. The company operates under the names of ChartwellCommunity Services, Inc., Chartwell Care Givers, Inc.,Chartwell Home Therapies, L.P., Chartwell ManagementCompany, Inc. and several joint ventures with leading medi-cal centers nationwide.

Chartwell Chooses ACHC

Join ACHC’s Team of Surveyors ACHC is seeking qualified Home Care surveyors inthe areas of Pharmacy, HME, Rehabilitation Technol-ogy. For more information, email your resume to em-ployment @achc.org.

2 SurveyorSpring 2005

Editor’s Note We apologize for errors in ourFall issue of the Surveyor News-letter.

On “ACHC Surveyors”, page3, we printed Tim Safley’s namewrong.

The UHS ad local phone num-ber was incorrect. Please see re-printed, corrected ad on page 15.

We miswrote the company nameof an accredited organization. Itshould have read Orthopedic Ser-vice Company of Raleigh, NC. All corrections have been madeto the downloadable newsletterposted on the web.

Michelle Holliday, Admin-istrative Assistant for SupportServices, has been with ACHCsince March of 2004. Shecame to ACHC with over 12years of administrative experi-ence in the health care indus-try. A native of Rocky Mount,NC, Holliday holds an Asso-ciates Degree in Criminal Jus-tice from Nash CommunityCollege and an Associates De-

gree in Network Technology from Edgecombe Commu-nity College. She is currently attending classes in pursuit of abachelor’s degree in computer science.

ACHC Staff

(File photo)Leslie Knuth.

(File photo)Michelle Holliday.

ACHC would like to con-gratulate Leslie Knuth on hernew position as Quality Assur-ance Manager. Knuth was for-merly the Director of Accredi-tation for ACHC. Knuth has been with ACHCsince April 2002. Before com-ing to ACHC, Knuth was a tech-nical auditor for a telecommuni-cations tower acquisition com-pany. Prior to that, she workedfor seven years with a healthcare consulting company, whichconducted mock surveys for hospitals undergoing JCAHOaccreditation. Knuth received her Bachelors Degree in Business Man-agement from North Carolina State University.

Need to prepare for HME mandatory national accreditation? Use ACHC’s“Standards for Accreditation Checklist” as a guide to:

• Increase your knowledge of HME industry best business practices • Audit your HME business • Determine if you are in compliance with local, state and Federal laws

To obtain your free copy, pleasecall Michelle at ACHC (919) 785-1214.

Accreditation Checklist

Want to advertise in our newsletter? The Surveyor newsletter is published under supervi-sion of the Accreditation Commission for Health Care,Inc. (ACHC) to provide health careorganizationswith information on people, policies,operations, trends and ideas. The ACHC Surveyor newsletter has a na-tional circulation of over 8,000 including butnot limited to ACHC accredited organiza-tions, as well as other registered mail listmembers such as publishers, state and na-tional associations, providers, consultants,government agencies, etc. For guidlines on how to submit an ar-ticle/advertisement, please refer to ourwebsite at www.achc.org/articles.htm.

3SurveyorSpring 2005

ACHC Surveyors

(File photo)Elizabeth Munoz-Chelette.

(File photo)Ed Dressen.

(File photo)John L. Davis.

Ed Dressen has over 22years of home medical equip-ment (HME) experience, with20 plus years in HME manage-ment.Prior to becoming a consultant,Dressen has practiced in the fieldof home health care in a varietyof roles including start-up man-ager for two hospital-basedcompanies. He has managedregional and national companies

as well and served as the President of the Illinois Associa-tion of Medical Equipment Suppliers (IAMES), providingleadership to the organization during the DMERCregionalization. As a manager of new branches and new start-ups, Dressenhas comprehensive knowledge of all aspects of HME op-erations and makes recommendations that will achieve thebest results for both the customer and the organization.

John L. Davis, PharmD,MBA, FASCP serves at the VPof Operations for LifeCare So-lutions East, Inc. In this role,John provides operational over-sight for the Clinical Pharmaciesand is responsible for operationalstandards of practice for thecompany. Davis has twenty-fiveyears of pharmacy experienceand over 20 years of manage-ment and home care experience.His professional experience includes Director of Pharmacyand General Manager positions with national home care or-ganizations including Nations Healthcare, Home Medical ofAmerica, American Home Patient, Home Nutritional Ser-vices and the Daughters of Charity Hospital System. He isalso Principal Consultant and Managing Partner in The LTCGroup, LLP, a Pharmacy coalition providing oversight tothe care of 2000 patients monthly residing in NE Floridaextended care facilities. Davis holds a BS degree in Phar-macy, along with post graduate Doctor of Pharmacy andMasters in Business Administration degrees.

Elizabeth Chelette is aNurse Manager, Inpatient &Residential Facilities for thePallative Care Center and Hos-pice of Catawba Valley in New-ton, NC. She has a Bachelorand Master’s degree in Nursingfrom Virginia CommonwealthUniversity in Richmond, Virginia,and she recently received herCHPN. Chelette won the 2001and 1997 Excellence in CaringPractice Award and the 1999 Innovation Award from theAmerican Association of Critical Care Nurses. She has pre-sented nationally for American Association of NeuroscienceNurses, American Association of Critical Care Nurses, aswell as the Carolinas Center for Hospice and End of LifeCare. Presentations include internationally for the Neuro-science World Congress in Rome, Belgium and Scotland.She has done mission work in Nairobi Africa . She is also acertified scuba diver.

Jim Noland has over 17years of experience in multipleareas of health care. This expe-rience includes adult and pedi-atric clinical care experience ina variety of inpatient acute, subacute and out-patient physicaltherapy settings. He also has ex-perience serving on a clinicalmanagement board for woundcare management while workingfor an HMO in Southern Cali-

fornia. He has over 10 years experience in clinical seating andpositioning, as well as over six years working in the custommobility and durable medical equipment industry directly.Noland’s experience during these years has always focusedon clinical education and outcomes-based assessment andequipment application. Noland is an honorably discharged veteran with an Ex-pert Field Medical Badge (EFMB) certification, as well as aformer member of local volunteer emergency services nearhis home town outside Cincinnati, Ohio.

(File photo)Jim Noland.


Provider SpotlightCaldwell County Hospice LENOIR, North Carolina- CaldwellCounty Hospice (CCH) is located in thenorthwest section of North Carolina, nestledin the foothills of the Blue Ridge Mountainsof Caldwell County. Caldwell County Hospice was estab-lished in 1982 by a group of community lead-ers to provide holistic care to terminally illpatients. CCH began in a borrowed Sun-day school room at the First PresbyterianChurch in Lenoir, North Carolina, with onepaid staff member and a handful of volun-teers. Miss Margaret Harper gave her hometo First Presbyterian Church at her deathwith the understanding it would be used spe-cifically for Hospice. The offices for CCHwere moved to Miss Harper’s home, knownas “Kirkwood”, in February of 1986. In 1989, Caldwell County Hospiceopened the first free-standing hospice pa-tient care unit, known as the William E.Stevens, Jr. Patient Care Unit (PCU). Thesix-bed PCU provides an alternative to tra-ditional medical facilities for hospice patients. Twenty-fourhour skilled care under medical supervision is provided toeach patient by our interdisciplinary team of a physicianmedical director, registered nurses, certified nursing assis-tants and an expert team of palliative care professionals.Attached to a stately old mansion, the six-bed PCU ex-presses warmth and a sense of timelessness. The unit’s de-sign and furnishings provide the feel of a home rather than aninstitution. The facility offers a relaxed living and dining environmentfor the families of patients who receive care in the unit. Ev-ery room is wrapped around a central terrace garden andhas its own private balcony overlooking Hibriten Mountain.Hospital beds can be moved into the court yard where pa-tients and family members may visit one another in a place ofnatural beauty. CCH holds to its reputation of expert care by continuallyproviding numerous services to all home care, long-term careand PCU hospice patients. Patients receive 24-hour skillednursing care, expert care in pain and symptom management,

medical social workers, counseling services for patients andfamilies, home health aids for personal care, chaplaincy ser-vices, trained patient/family volunteers to provide added sup-port and friendship and bereavement care for families fol-lowing the death of their loved one. CCH also provides additional community outreach ser-vices including a Transitions program for persons living witha life threatening illness but not appropriate for hospice careand community bereavement services. Recently, CCHopened a new grief support and counseling center, knownas Ashewood, for the community to receive guidance onhow to deal with the pain and loss of a loved one. The cen-ter is used for individual and family grief counseling and sup-port groups. Additional services provided to the community are edu-cational workshops, programs for schools, community groupsand in the workplace. In 2001, CCH developed TheCaldwell Partnership for End of Life Care. The purpose ofthe partnership is to get the community involved in address-

Continued on Page 14

(Courtesy photo)The offices for Caldwell Community Hospice (CCH) were moved toMiss Harper’s home, known as “Kirkwood”, in February of 1986.CCH was among the first hospice providers to be accredited by theAccreditation Commission for Health Care.


ACHC Accreditation Services

Organizations pursuing accreditation with the Accredita-tion Commission for Health Care, Inc. (ACHC) are requiredto prepare and submit a Preliminary Evidence Report (PER)a minimum of eight (8) weeks prior to scheduled survey.This self-assessment process is an essential and effectivetool in preparing for survey by providing evidence of stan-dards compliance. The purpose of the PER is for the orga-nization to measure self-compliance and for the surveyor tobecome familiar with the organization’s policies and proce-dures before the on-site survey. The PER enables the sur-veyor to assess the organization’s preparedness for survey,as well as offer suggestions and recommendations for theorganization’s minimum and/or improved standards compli-ance. Following the simple step-by-step procedure for assem-bling the PER is imperative to enable the surveyor the mostquality assessment of the material submitted. Each standardand criterion are listed on submission requirement pages ofthe PER. The evidence to be submitted is listed under eachstandard in a check-off format. By following the step-by-step PER preparation process,the PER can be assembled and processed with maximumbenefits.

Preliminary Evidence ExampleStandard 101. Legal Authority. The organization is anestablished entity with legal authority to operate.

Standard 101, Criterion A: There is appropriate licen-sure, Articles of Incorporation, or other documentation oflegal authority.

Note: Failure to meet this criterion will be assessed bythe ACHC Review Committee and may result in auto-matic deferral.

Submit the following items labeled according to stan-dard and criterion:

_____Copy of Articles of Incorporation/Bylaws and allapplicable amendments

_____Copy of current license/permit for each premise

Check-Off Process:1. Locate and copy the Articles of Incorporation/Bylaws,all applicable amendments and a copy of the current li-cense/permit for each premise.

2. Write Standard 101, Criterion A at the top of eachpage.

3. Place the PER requirement page with the items sub-mitted checked off in an expandable folder with the sup-porting evidence labeled accordingly behind it.

ACHC provides an Interpretive Guide to standards in Sec-tion 3 of each manual sold. This Interpretive Guide shouldbe used as a reference tool to support preliminary evidencepreparation.

Step-By-Step ProcedureOther submission formats, such as three-ring binders slow the survey process. Eachorganization is supplied with an expandable folder to collect and sub-mit PER materials. The applicant organization is instructed to:

1) place the submission requirement page into the expandablefolder;

2) place the evidence required on the check-list into the ex-pandable folder behind the submission requirement page.


by Robert Thompson, PresidentAspirant Education, Inc. One of the most ignored and poorly communicated fed-eral requirements is the Medicare Exclusion Program. TheOffice of Inspector General (OIG) of the Department ofHealth and Human Services (DHHS) is tasked with the iden-tification and elimination of fraud, waste and abuse in theDepartment’s programs, which in-clude Medicare. The OIG carries outnationwide audits, inspections, andinvestigations and they have the au-thority to exclude any individual orentity from participation in Medicare,Medicaid and other federal healthcare programs. With the enacting of the Health In-surance Portability and Accountabil-ity Act (HIPAA) of 1996, PublicLaw 104-191 authorized the OIGto provide guidance to the healthcare industry to prevent fraud and abuse, and to promotehigh levels of ethical and lawful conduct. To further thesegoals, the OIG issues Special Advisory Bulletins about in-dustry practices or arrangements that potentially implicatethe fraud and abuse authorities subject to enforcement bythe OIG. Each company should monitor and carefully re-view each of these Special Advisories. To sign up for freenotification of these Special Advisories, visit http://list.nih.gov/cgi-bin/wa?SUBED1=hhs-oig-media-l&A=1. The OIG, under Congressional mandate, established aprogram to exclude individuals and entities from participa-tion in Federally-funded healthcare programs. The OIGrecords and maintains a list of all currently excluded partiescalled the List of Excluded Individuals/Entities (LEIE). Rea-sons for being placed on the LEIE list include convictionsfor program-related fraud and patient abuse, licensing boardactions and default on Health Education Assistance Loans.The LEIE contains only exclusion actions taken by the OIG. The Balanced Budget Act of 1987, Public Law 100-93,authorized the imposition of Civil Monetary Penalties (CMP)against health care providers and entities that employ or en-ter into contracts with any excluded individuals or entities toprovide items or services to Federal program beneficiaries.This means hospitals, nursing homes, medical equipmentproviders, pharmacies and home health providers may face

Medicare Exclusion ProgramCMP if they submit claims to a Federal health care programfor health care items or services provided, directly or indi-rectly, by excluded individuals or entities. In practical terms, the OIG exclusion is to prevent em-ployment of an excluded individual in any capacity by a healthcare provider that receives reimbursement, indirectly or di-rectly, from any Federal health care program. If a health

care provider arranges orcontracts with an excludedindividual or entity, the pro-vider may be subject toCMP liability of $10,000for each item or servicefurnished by the excludedindividual or entity. Healthcare providersare obligated to check theexclusion status of individu-als and entities prior to en-tering into employment or

contractual relationships. The OIG urges health care pro-viders and entities to check the LEIE prior to hiring or con-tracting with employees or entities, and periodically throughouttheir employment. An organization can check their employ-ees (five at a time) against the LEIE by going to http://exclusions.oig.hhs.gov/search.html. DMETRAIN.com, theemployee training company, provides an automatic daily LEIEcheck for all employees added to its service and sends quar-terly email reports that can be used to prove an organization’scompliance. We live in a world where fraud and abuse appear to beeveryday occurrences, and it is in all of our interests to doour part to make sure all applicable laws and regulations arefollowed. Compliance is a necessity, not a luxury. Whetheryour organization signs up with companies like DMETRAIN,or performs all the required compliance activities on theirown, compliance is the cornerstone to a successful future. All of the information provided in this article is availableon the OIG’s website http://oig.hhs.gov/. Robert Thompson is the President and CEO of Aspirant Educa-tion, Inc. which the developer of the employee learning manage-ment system DMETRAIN. Robert has a Bachelor’s of Science inNursing and is licensed as a Registered Respiratory Therapist anda Registered Nurse. Robert has over 22 years experience inhealthcare and is the former owner of a chain of medical equip-ment stores in California. DMETRAIN provides industry-leadingonline employee education, competency training, and accredita-tion compliance. Tollfree 877-872-4633. www.dmetrain.com


5816 Creedmoor Road, Suite 201 Raleigh, NC 27612 (919) 785-1214

“Everyone at our company had nothing butpositive remarks following the survey ... theadvice and feedback from our surveyors was

extremely beneficial.”

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~Rhonda L. Schultheis, RN, BSNClinical Operations Manager

Williams Bros. Health Care Pharmacy

Offering accreditation in:*Aide

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to find out more visit

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uHIPAAu’s ASTD certified HIPAA Essentials program offers “thirdparty” verification on all certifications. No more guess work abouthow well your staff understands and can apply the HIPAA com-pliance regulations.

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NHIANew Orleans, LAFebruary 10 - 13

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by Floyd E. Boyer, RRT, RCPACHC Clinical Consultant

Introduction Rehabilitation Technology ser-vices are defined as the applica-tion of enabling technology sys-tems designed to meet the needsof a specific person experienc-ing any permanent or long-termloss or abnormality of physicalor anatomical structure or func-

tion. These services, prescribed by a physician, primarilyaddress wheeled mobility, seating and alternative position-ing, ambulation support and equipment, environmental con-trol, augmented communication and other equipment andservices that assist the person in performing their activities ofdaily living. Rehabilitation Technology services facilitate and/or enhance access and independence thereby improving theperson’s quality of life. The Accreditation Commission for Health Care, Inc. isthe only organization to provide accreditation specific to Re-habilitation Technology Suppliers (RTS). The work on thisproject began in the spring of 2001 upon the request of anumber of Rehabilitation Technology Suppliers. The indi-viduals informed ACHC of the need for an accrediting bodyto have a set of standards that are written specific to Reha-bilitation Technology Suppliers. Several of the companieshad been through Home Medical Equipment (HME) surveyby other accrediting bodies. The companies’ major concernswere that Rehabilitation Technology is a specialized indus-try, that many of the HME standards are not applicable toRehabilitation Technology and that the surveyors themselveshad little or no experience with Rehabilitation Technology. ACHC completed its Rehabilitation Technology Supplierstandards in August 2002 and since that time has accredited7 RTS organizations, with a total of 21 locations, includ-ing 1 national company. All ACHC standards undergoperiodic review and update. The revision of RTS standardshas been completed and the new standards will be ready forpublication and dissemination to RTS companies in January2005.

Rehabilitation Technology SupplierAccreditation

What Makes RTS Different. A key element that differentiates Rehab Technology Sup-pliers from HME companies is the process required to evalu-ate Rehab Technology clients’ needs. Rehab TechnologySuppliers conduct individualized evaluations of clients’ Re-hab Technology needs in order to provide them with themost appropriate equipment to meet their needs. The evalu-ation is conducted in the environment in which the client willbe utilizing the adaptive equipment and includes input fromother health professionals such as a Physical Therapist, Oc-cupational Therapist and the client’s physician. An integralpart of the evaluation is the clear identification of the client’sgoals relating to what they need or want to achieve in termsof their individual medical and functional needs. The finalfitting of rehabilitation technology products should take placein the client’s home or work environment to assure that theproduct is suitable and that it fulfills the client needs. Theclient evaluations must be performed by a Certified RehabProfessional who is defined as one who has successfully at-tained the title of Certified Rehab Technology Supplier(CRTS) 1, Assistive Technology Supplier (ATS) and/orAssistive Technology Practitioner (ATP) 2

The physical plant needs differ greatly from standard HMEcompanies. The Rehab Technology Supplier must have desig-nated room(s) for evaluation and fitting that are private, cleanand safe for the client and comply with the accessibility stan-dards of the Americans with Disabilities Act. The Rehab Tech-nology Supplier must offer the client an assortment of productsto improve the selection process in determining the item(s) thatbest serve the client’s needs, goals and objectives. In order todetermine product suitability and to appropriately meet the needsof the client, the Rehab Technology Supplier must provide ei-ther the exact item to be purchased or a close facsimile to prop-erly demonstrate its effectiveness. The Rehab Technology Sup-plier must be able to provide loaner equipment to clients whiletheir equipment is being repaired. In addition to serving the client’s equipment and serviceneeds, Rehab Technology Suppliers have a much more

(File photo)Floyd E. Boyer.

‘As awarded by the National Registry of Rehabilitation Tech-nology Suppliers (NRRTS)2As awarded by the Rehabilitation Engineering and AssistiveTechnology Society of North America (RESNA)


personalized involvement with each individual client. This in-cludes assisting clients with the funding process, informing themof their options, negotiating with payers for coverage and reim-bursement, and complex claims processing. The Rehab Tech-nology Suppliers must employ trained and qualified personnelin order to facilitate this process. Rehab Technology Suppliersmust offer their clients accurate pre-screening of coverage andpayment options so the client is aware of all funding issues.Also, Rehab Technology Suppliers must provide education forthe client’s other healthcare providers (doctors, therapists, andsocial workers), who may not know about the Rehab Technol-ogy process or the funding issues involved.

Review of Standards This section will summarize the Accreditation Commis-sion for Health Care’s scope of service section of the RTSaccreditation manual. The section is not meant to take theplace of the complete manual for accreditation that is avail-able from ACHC. The section does not include ACHC’score standards for accreditation, which outlines the neces-sary facility requirements related to administration, fiscal man-agement, personnel management, quality improvement andrisk management. Rehabilitation Technology Supplier services must be pro-vided in accordance with accepted ethical and industry stan-dards, as well as all applicable local, state and federal stat-utes. Rehab Technology companies must employ at leastone Rehab professional per location. The supervisor of ser-vices must be a Certified Rehab Technology Supplier(CRTS), an Assistive Technology Supplier (ATS) or anAssistive Technology Practitioner (ATP). Rehab Technol-ogy companies must employ at least one trained technicianper service center that has attended an industry-wide tech-nician-training program. Customer Service/Billing staff mustattend an industry-sponsored customer service/billing train-ing course(s). The company must pursue communication and interac-tion with other rehabilitation suppliers in order to maintainthe standards of professionalism, increase awareness of ser-vices and products, improve overall product quality andenhance product and service development within the field. The company must have written policies and proceduresthat describe the process for provision of services to its cli-ents. The scope of services section must include, at a mini-mum, the following written policies and procedures: The types of services/equipment provided, target clientpopulations and goals of the program.Hours of operation and how after-hours calls are documentedand responded to.

The process for client evaluation/assessment of need,development of the plan of service and frequency and theprocess for the plan of service review. The evaluation mustbe conducted in all appropriate settings to include the client’shome, school and work environment, as applicable. Theevaluation must include input from other health professionalssuch as the client’s Physical Therapist, Occupational Thera-pist and Physician.

How the Client is Involved in the Development of thePlan of Service and any Changes to the Plan. Describe the education of the client including the properuse of products provided, safety hazards associated withproducts provided, maintenance of equipment, plan of ser-vice and how to notify the company of problems, concernsand complaints. Written instructions must be provided to theclient regarding the safe use and care of any equipment/sup-plies provided. Transfer and discharge policies and procedures. How areclient transfers and/or discharges documented in the clientrecord? The cleaning, storage and transportation of client-readyequipment. The separation of dirty equipment from client-ready equip-ment in the warehouse and delivery vehicles. The warehousing and tagging of equipment. The use of cleaning and disinfecting agents and process-ing of contaminated or soiled equipment, including curbsidedisinfection. The set-up, delivery, environmental requirements and elec-trical safety of the equipment. The maintenance and repair of equipment.

Continued on Page 13


by Barbara Stover Gingerich, RN MS FACHE CHCE With the work of the National Patient SafetyFoundation(NPSF) taking a front row seat in the news andthe global emphasis on safety and security, health care findsever increasing scrutiny of its safety initiatives. That meanspatient safety and safety initiatives must extend beyond ex-isting practices and become more proactive and expansivein scope. The National Patient Safety Foundation’s NationalAgenda for Action: Patients and Families in PatientSafety identifies initiatives in four important areas. They are:education, culture, research and support services.[npsf.2003] The Agency for Health Care Research andQuality[AHCQ]also focuses on patient safety and medicalerror, as does the Institute for Safe MedicationPractice[ISMP]. These initiatives in combination with na-tional and governmental emphasis on safety make it impera-tive that the organization takes steps to increase safety anddecrease errors.

Prevention Steps to Undertake1. Provide education and create awareness It is essential to educate staff, consumers, referral sourcesand interdisciplinary health care professionals on patient safetyimportance, as each individual is a vital link in the care deliv-ery continuum. A well-informed consumer allows the indi-vidual and his family to become an active member of thecare team. Provide consumers with hints on how to safe-guard their safety and provide staff with steps to take to

insure patient safety. This strengthened team willaid in identifying and eliminating potential problemsituations or concerns.

2. Establish a win-win environment/care cul-ture. Establishing open communication pathwaysbetween caregivers, staff, consumers and man-agement creates a culture where problems areidentified and steps taken to address and elimi-nate the problem, not the individual[s]. Familiesand patients should be encouraged to share infor-mation about their lifestyles and their use of over-the-counter, herbal or natural remedies and treat-ments, so that a complete assessment of thepatient’s treatment plan and needs can be con-structed. Without a complete picture, the poten-tial for patient injury becomes greater.

3. Create patient safety initiatives. Through self-audits and research, identify key

Patient Safety:What Should YourOrganization Be Doing?

Stating the Problem: Did you know that...

over the years 2000-2003, the U.S. Congress has awarded to theAgency for Healthcare Research and Quality $165 million to be dedi-cated to patient safety research?[The Commonwealth Fund 2004]

a National Patient Safety Foundation poll found that 42 percent ofindividuals surveyed reported they had been affected by a medicalerror [personally, friend or relative].[AHRQ 2000]

using the lower of the Institute of Medicine[IOM-44,000 deathsannually] estimates medical errors rank as the eighth leading causeof death in the United States?[ IOM 1999]

about 7,000 people are estimated to die each year from medica-tion errors?[AHRQ, 2002]

a case study of two large hospitals revealed errors in ordering [56percent] and administering medicines[34 percent] led to preventableadverse drug events, with failures at the system level accounting forover three fourths of adverse drug events?[AHRQ, 2002]


processes/activities that have an increased potential for nega-tively impacting patient safety efforts. Then integrate findingsinto its quality improvement program with quality initiativesfocused on these identified risk areas. A patient safety taskforce can assist the quality improvement staff in this endeavor.

4. Identify external and internal supports. Is your staff aware of the available external resources, suchas national resource centers, information line, emergencyhotlines, MedWatch alerts, recalls? If not, this should be in-cluded in the orientation of new staff to the organization and bea planned topic in an annual inservice education program.

5. Establish a safe medication administration continuum.The key steps in the medication administration continuumare:

PrescribingTranscribingDispensing

StoringAdministering

Monitoring[Gingerich2004]

It is important to put safeguards in place at each stepwithin this continuum. For example, when the medication isbeing ordered via a verbal order process, there are severalhealthcare professionals involved in the prescribing, order-ing, transcribing and dispensing steps. Each professionalneeds to be knowledgeable about medications and be alertto record exactly what was ordered. Each individual mustbe comfortable asking the other individuals involved in thestep questions relative to the type, amount and reasons forthe medication. Accuracy, detail and completeness of medi-cation information are essential in these steps and all steps inthe process. Checks and balances should be in place to as-sure these essentials are present. [Gingerich2004]

6. Put documentation safeguards in place. There are many examples of dangerous abbreviations anddosage designations available through the Institute for SafeMedication Practice (ISMP). In addition to this resource,the United States Pharmacopeial Convention, Inc. (USP)provides current information on medication errors trackedand trended as part of the Medication Error Reporting Pro-gram (MERP).[Gingerich2003] Using these resources toestablish documentation safeguards is critical to decreasingdocumentation-related medication errors. Some examplesof Unacceptable Abbreviations to make part of your Do

Not Use documentation list include:

qn – This has been misread to be “qh” instead of nightlyor at bedtime as intended.

D/C- This can be confused to be either discharge or dis-continue.

IU- This means international unit, but has been misreadby staff to mean IV-intravenous.[ISMP2003]

Summary This article highlights a few of the many steps to take toincrease patient and consumer involvement in care, increasepatient safety and decrease medication and/or documenta-tion errors. The next step is to look internally within yourpractice and your organization to identify and address thathave a potential for harm to both patients and staff. Identi-fication and elimination of risk must be an ongoing part ofeach day.

References/Additional ResourcesAgency for Healthcare Research and Quality. Medical Errors:The Scope of the Problem. An Epidemic of Errors. PublicationNo. AHRQ 00-PO37.February 2000.

Agency for Healthcare Research and Quality. 20 tips for Pa-tient Safety. 2002.

Gingerich BS. Compliance Concerns: The Importance of Docu-mentation NHPCO Insurance Newsletter. Summer 2003.

Gingerich BS. The Medication Administration Continuum: Pre-scribing and Administering Safety. Part I. NHPCO InsuranceNewsletter. Winter 2004.

Institute of Medicine. To Err is Human. November 1999.The Commonwealth Fund. Washington Health Policy Week inReview. Survey: Five Years After IOM report, Medical ErrorsStill a Major Concern. November 17, 2004.

www.ismp.org. ISMP. Do not use these dangerous abbrevia-tions or dose designations.2003.Accessed November 26, 2004.

National Patient Safety Foundation’s National Agenda for Ac-tion: Patients and Families in Patient Safety. 2003 NationalPatient Safety Foundation’s Patient and Family Advisory Coun-cil: Herndon VA.

Barbara Stover Gingerich RN MS FACHE CHCE is president ofAdvantage Consultants, Inc and an adjunct faculty, Department ofNursing, York College of Pennsylvania. For further informationcontact her at ADVANTAGE Consultants, Inc 204 St Charles WayUnit #E363 York PA 17402, telephone: 888-672-9843, fax 717-812-9877, email: [email protected]. For more informa-tion about services offered through Advantage, you can access thecompany’s website at: www.advantagehcmrgroup.com.


by Barbara Rosenblum, CEOStrategic Healthcare Programs (SHP) If you’re like most clinical and operations man-agers, you’re clamoring for information to helpyou run your business more efficiently and im-prove patient care. Whether your practice areais Home Health, Hospice, Home Infusion orRespiratory Care, business intelligence datahelps you maintain financial health while dem-onstrating good outcomes. One important event to monitor within andbetween your service lines is hospitalizationrates. Why? Dependent on your areas of prac-tice, hospitalizations can result in everything fromlost revenue to public reporting of your out-comes by CMS. Most important, a hospital-ization is usually a disappointing event for thepatient, family and referring physician. It is nevera positive event for the payer of services. Let’sexamine how hospitalization rates compare between HomeHealth, Infusion and Hospice. Hospitalization rates from the Strategic Healthcare Pro-grams (SHP) database are reported per 1000 services days.Although the rate calculations for hospice use somewhat dif-ferent inclusion criteria (National Hospice Palliative CareOrganization –NHPCO), the datastill provide mean-ingful comparisonsand trends. Dataare provided frommost current to 3quarters retrospec-tive. Home healthagencies (Medi-care-certified) havethe highest hospitalization rates. The rates have increasedover the last 12 months. Managers need to address theirhospitalization rates to determine what is contributing to thisincrease, and that requires objective, easily retrievable drill-down information provided in real-time. Is the increase dueto a change in the types of patients being admitted? Do the

Monitoring Performance Across Service Lines:Industry Benchmarks for Hospitalization Rates inHome Health, Infusion and Hospice

Hospitalizations per 1000 service days

Type of Service Q3 2004 Q2 2004 Q1 2004 Q4 2003Agencies* 4.67 4.73 4.64 4.30Infusion 1.12 0.99 0.85 1.01Hospice 0.29 0.28 0.21 0.33

*CMS risk adjusted rates are available from SHP.

change coincide with a change in personnel or staffing ra-tios? Infusion providers have substantially lower hospitaliza-tion rates than home health agencies (1.12 versus 4.67 inQ3 2004). The rates have increased over time, just as withhome health agencies, but to a significantly lesser degree.

When a patient is admit-ted to the hospital from ahome infusion setting, thisis typically accompaniedby lost revenue for theprovider. Managers need to de-termine what is currentlycontributing to these hos-pitalizations and how thatcompares to previousquarters. Are most of the

hospitalizations due to clinical decline? Or, are they relatedto vascular access issues? If so, what type and brand ofcatheter? Was the hospitalization a result of an adverse drugreaction? If so, what drug? What was the severity of thereaction? What steps could have prevented these hospital-izations?


Hospice providers have the lowest hospitalization rateamong the three groups. Although they care for the sickestpatients, the practices and goals of hospice are different fromthose of home health agencies and infusion providers. But,unlike the other two groups, hospice hospitalization ratesare on the decline. Hospice providers are successful at keeping patientsout of acute care settings, and are improving. Managersshould determine what practices are contributing to thisimprovement and reinforce them. How does your data compare to that presented in thisarticle? If you had access to this data, how would it bringvalue to your organization and what would be the returnon investment? A study conducted by SHP last year con-cluded that a typical infusion provider in the SHP data-base, with an average daily census of just over 100 pa-tients, could lose almost $45,000 per year in expectedrevenue due to unscheduled hospitalizations. Growing hospital rates for home health agencies cantrigger a cascade of events and will ultimately affect theagency’s scores on CMS’ Home Health Compare. Ifhospitalization rates are decreasing, as they are amonghospice providers, that knowledge can be utilized to toutquality performance and becomes a valuable marketingtool, thereby increasing referrals. Today it is possible for managers to quickly and effi-ciently obtain a vast amount of information for all theirlines of business. Browser-based business intelligenceprograms allow users to track and trend their operationaland clinical performance, protect outcomes scores, moni-tor patient satisfaction with services, and benchmark datawith peers in each sector. Furthermore, this data is beingused in aggregate form to educate legislators and payersabout the important role that home care plays in thehealthcare continuum. Organizations will continue to diversify and offer moreservices to patients. In support of those goals, ACHCand SHP share a common vision with and approach tothe post-acute market. ACHC and SHP workcollaboratively to help organizations achieve the highestlevel of quality performance. For more information, con-tact either ACHC or SHP. Strategic Healthcare Programs (SHP) offers enter-prise-wide and single site business intelligence programsto the post-acute market: Infusion, Hospice, HomeHealth, Private Duty, Telehealth, HME, Respiratory,Long Term Care, Ambulatory Surgery. For more infor-mation, visit www.shpdata.com or call 805-963-9446.

The separation of inoperative equipment. The tracking of equipment and procedures relating tomanufacturer recalls. Define the training, qualifications and skill validationrequired by personnel to perform routine maintenanceand repair of all RTS equipment. Define the use of out-side repair sources. How equipment assembly is documented. The provision of on-site services including the acces-sibility standards of the Americans with Disabilities Act. The provision of equipment for demonstration, simu-lation and trial. The loan of equipment to clients. Equipment and product warranty.

During the ACHC accreditation survey process thesurveyor will collect data to document the following: (1)the company has written policies and procedures thatcomply with ACHC standards; (2) all staff members areeducated and understand the company’s policies andprocedures; (3) clients are educated per the company’spolices and procedures; and (4) staff members complywith the company’s policies and procedures and ACHCstandards.

Summary This article was written to provide a short review ofthe ACHC accreditation standards and survey processfor Rehabilitation Technology Suppliers and educate otherHome Health care organizations as to the difference be-tween Home Medical Equipment companies and Reha-bilitation Technology Suppliers. It is my hope that those RTS companies that are notcurrently accredited or which are accredited by otherbodies will consider ACHC for accreditation. As youare aware, the Centers for Medicare and Medicaid arecurrently discussing how to implement the law passedby Congress last year that will require all DMEPOS com-panies to be accredited. It is not known how CMS will interpret the law andwrite regulations to enforce the law. Whatever the out-come, RTS and HME companies that are not currentlyaccredited should start now to prepare for accredita-tion.

Rehabilitation TechnologyContinued From Page 9

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Consulting: Mock surveys and accreditation consulting by ACHC Pharmacy Surveyor USP <797> consulting and gap analysis (via agreement with Clinical IQ, LLC) Infusion pharmacy operations consulting and assistance with software evaluation

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Continued From Page 4

The first annual HME VIP Summitwas held in December at the CountryClub Plaza in Kansas City, MO. At-tendees raved about this meeting for-mat as being so much more valuablethan any trade show they have ever at-tended. Steve Cole of Dedicated Distribu-tion developed this unique one-on-onemeeting venue for HME businesses andmanufacturers. Vendors held 15-minutelong meetings with attendees in theirsuites for one-and-a-half days. Attend-

First Dedicated Distribution HME VIPSummit A Great Success

ees were able to focus on categorymanagement and strategic planning, andlearning how to grow their business byeach vendor in that respective category. HME business owners and pharmacistswere not bothered by in-store concernssuch as customers, telephones ringingand staff asking questions. Vendorswere not fighting the distractions of be-ing on a trade show floor. The second day attendees also par-ticipated in roundtable sessions withrenowned HHC industry consultants.

They moved from table to table to meetwith Jack Evans about marketing andsales, Jeff Baird about regulatory issues,Bruce Brothis about billing issues, TomCesar, ACHC president, about accredi-tation and Ed Lemar about showroom de-sign. The intimate setting provided fortime to focus on individual concerns. Response was so positive that Dedi-cated is already planning another HMEVIP Summit for 2005. For further in-formation please contact Steve Cole at800 325-8367, ext. 11

Caldwell County Hospiceing end of life issues including, but not limited to, hospice. Currently,the partnership has 19 community members and has participated invarious health fairs within the community. This fall the partnershiporganized for national author, Andrea King Collier, to speak to thecommunity, emphasize the importance of end of life care issues andplanning. Since that time, the partnership has distributed many advance caredirectives and a number have been executed. The partnership contin-ues to grow in size and is building an exciting plan for the comingfiscal year. Caldwell County Hospice was among the first hospice providersto be accredited by the Accreditation Commission for Health Care.CCH earned their first accreditation in 1998 and has earned reac-creditation in 2001 and 2004. Accreditation is one way CCH con-tinues to maintain its commitment to quality care and remain centeredon each patient’s needs. Since its inception in 1982, CCH has served more than 3,500terminally ill patients and thousands more family members. CCHstaff has grown to over 60 employees, including a full-time medicaldirector, registered nurses, home health aids, administrative staff andsupport services staff. The organization is a non-profit independent corporation, which isgoverned by a voluntary Board of Directors. CCH is accredited bythe Accreditation Commission for Health Care, licensed by thestate of North Carolina to provide hospice care and is certified toreceive Medicare and Medicaid.


What are peoplesaying about

ACHC?

~George S. Kucka, R.Ph.President

Fairmeadows Home Health Center, Inc.

Community HomeCare, affiliate of the University of IowaHealth Care, has renewed its accreditation with ACHC. UICommunity HomeCare, a full-service medical equipment andinfusion services provider, offers patients and families con-venience and peace of mind. They provide optimal continu-ity and consistency of care through appropriate prescribedmedical therapy or aid at home for as long as necessary.Through their affiliation, they can provide optimal continuityand consistency of care. Many of the physicians and spe-cialists at the hospital have helped develop their policies andprocedures, so that home care will be delivered accordingto patient preferences. In addition, they provide care in asimilar manner as the hospital, so patients will be familiarwith the procedures. “I highly recommend ACHC. Their standards are straight-forward and you know exactly what is expected of you, noreading between the lines or interpretation needed. The modelthey follow, utilizing the PER review, is outstanding. Whenyour surveyors arrive on site, you feel like they really knowyour organization and you can utilize them as consultantsand learn from their experiences. We have been throughACHC initial accreditation and re-accreditation and Iwouldn’t think of utilizing anyone else,” commented Execu-tive Director Danette Frauenholtz. The collaboration with the University of Iowa HealthCare, brings together the expertise of highly skilled healthcare professionals and sophisticated medical technologiesto serve the people of Iowa and beyond. U.S.News & WorldReport has consistently ranked UI Hospitals and Clinicsamong “America’s Best Hospitals” since the rankings beganin 1990.

University of Iowa CommunityHomeCare Renews

UHSHealth Care Resource Network

United Health StandardsPO Box 3763

Wilmington, NC 28406(910)762-0050 or 1-800-820-8178

[email protected]

Management ♦ Development Policies & Procedures

Survey Preparation, HIPAA ResourcesPermanent Staffing, and more

“…the ACHC experience was very positive.The surveyors were experienced home medi-cal equipment services and pharmacy individu-als who conducted themselves not only pro-fessionally, but in a colleagulial manner. Thesurvey was reasonably priced and the infor-mation shared by the surveyors was very valu-able, and has led to improvements in some ofour operations.”

“During our 8 years of association withACHC, our experience has been a positive andproductive one. I know ACHC to be fair, ob-jective and very knowledgeable in their ser-vices. The review process has been both edu-cational and informative.”

~Larry LankfordPresident

Healthcare Equipment, Inc.

“Fox felt that ACHC and Fox were workingtoward a common goal and had a partnership.We received constructive criticism and infor-mation that we feel have assisted Fox in pro-viding better service to our patients/clients.”

~Francis MartinPresident-CEO

Fox Med-Equip Services


ACHC Congratulates Its Newest Accredited Locations

Non-Profit Org.U.S. Postage

PAIDRaleigh, NC

Permit No. 525

RETURN SERVICE REQUESTED

5816 Creedmoor Road, Suite 201Raleigh, NC 27612

(919) 785-1214 www.achc.org

A & D Healthcare, LLC - Corporate; TN (6 branches) HMEAeroflow, Inc.; NC (0 branches) HMEBernens Convalescent Pharmacy; OH (0 branches) HMEChartwell Ohio; OH ( branches) HINFChartwell UCD Health System; CA (0 branches) HINFConnecticut Rehab and Medical Products; CT (1 branches) RHBTCDare Home Health & Hospice; NC (0 branches) HSPDavie Medical Equipment, Inc.; NC (0 branches) HMEFour Points Home Medical dba Tripp Corporation; NC (0 branches) HMEFranklin County Home Health Agency; NC (0 branches) HHHealth Technology Resources; IL (0 branches) HMEHome Care Equipment; VA (1 branches) HMEHome Health and Hospice of Halifax; NC (0 branches) HSPHome Nursing Care, Inc DBA Community Home Care Services; VA (1 branches) HMEHospice at Greensboro, Inc.; NC (0 branches) HHHospice of Tuscarawas County; OH (2 branches) HSPIdeal Home Medical Supply, Inc. - Powhatan; VA (2 branches) HMEInfusion Care of South Carolina, Inc.; SC (0 branches) HINF

IV & Respiratory Care, LLC; IL (0 branches) HINFJabez Home Infusion; NC (0 branches) HINFLink Medical, Inc.; NC (1 branches) HMEManns Home Medical Products; PA (0 branches) HMEMedAssist Medical; CA (0 branches) HMEMedical Home Care, Inc.; AL (0 branches) HMEMedical Solutions of America, Inc.; NC (0 branches) HMEMedi-Rents & Sales, Inc.; MD (0 branches) HMENewSouth HealthCare; NC ( branches) HHNorthampton County Home Health Agency; NC (0 branches) HHPersonal Support Medical Supplies; PA (0 branches) HMERG Respiratory, Inc.; PA (0 branches) HMERoyal Medical; PA ( branches) HMESouthern Pharmaceutical; MS (0 branches) HMEStanly County Home Health Agency; NC (0 branches)HHThe Forms Boutique, Inc.; SC (0 branches) WHCPTotal Home Care, Inc.; NC (0 branches) HMEUnique Boutique, Inc.; NC (0 branches) WHCPUniversity of Iowa Community HomeCare, Inc.; IA (0 branches) HINFVNA Home Health of MD LLC; MD (0 branches) HHWilson County Home Health; NC (0 branches) HH

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