responses- facility accreditation advice

responses- facility accreditation advice

Joan K. Cestaro, CP

9/11/2003

Thank you to everyone who responded and provided advice. Many asked for
a posting of responses.
Joan K. Cestaro, C.P.
RPI- Virginia

Original posted question:

We are in the final stages of preparing our facility for ABC
Certification and I am seeking any last minute suggestions and/or advice
for preparation prior to filling out the application. I am curious as
to what types of questions they may pose to our staff and where the
specific areas of interest lie. What are the main areas of interest or
focus? Were you ill-prepared for anything? Or was anything unexpected
or surprising? Did their manual prepare you adequately?

Responses:
It's been a while, but I have performed several site surveys for ABC.
The process should be very clear-cut. The surveyor is there to observe
and record the findings. That report is forwarded to an ABC committee
for a final decision. If you followed each of the requirements you will
do fine. A common error that I have observed is that some facilities
developed policies that required much more than ABC requires, yet they
failed to comply with their own policies. It seemed as if they wanted
to impress ABC by having a terrific set of policies, yet they did not
comply and members of their staff were not aware of these policies. If
you state that you do something, then do it. Each of your staff should
be aware of your policies and what they require. The published
standards are an excellent guide for the process. A good example of
this is when I asked a front office staff of three which one of them
were CPR trained. They replied that none of them were. It turned out
that no one in the entire organization was CPR trained. Yet, the
written policy stated that each and every staff member was required to
maintain CPR training. This is much more than ABC standards dictate.
If anybody gets surprised, it is usually the surveyor.

At least when I had it done for our facility, one practitioner showed up
and basically followed the manual. Not intimidating at all. Very low
key.

Here is a shopping list:

1. OSHA compliance ie, air purification, eyewear, earwear,airway
protection,
maintanance logs flammable chemical control, CPR ceritfications, etc.
2. Patient chart notes, medicare compliance, HIPPA compliance, patient
rights,etc.
3. Corporate documentation, mission statements, minutes, operational
manuals,
etc
4. Practitioner ABC Current status - they want to see the certificates,
Licensure status, etc

ABC should have sent you a workbook which includes a self audit. I found
this very helpful. One thing they seem to key into is a quality
assurance program with verifyable results.

I recently completed my facility accreditation. The manual is of
valuable resource. If you did all your documentation's with the manual
chapter by chapter, you should have no problem. There is no staff
interview of any kind. The inspector deals directly with who is in
charge. The whole process takes less that two hours. Your documentation
is very important. Good luck.

It is virtually impossible to fail ABC Accreditation Site Visit. Even if
something is inadequate, they will still give you the Accreditation with
a provision in small font that you must improve certain areas. I know a
company that became recently accredited not having a wheelchair
accessible bathroom (?!) I think you will only fail if you are running
your business from your garage or the trunk of your car. It is
unfortunate, but true.