By Lynn Serra RN, BA, MBA
Senior Consultant
Beth Carpenter and Associates
This is the second in a two part series about the Accreditation Commission for Health Care, Inc. (ACHC).
Last month, we covered the questions: How long does it take to become accredited? How much does it cost? So let's take a look at some of the specifics of ACHC processes and some suggestions they make. I call it the ACHC Top 10 List.
10. Unfortunately, no matter how hard you try, you will not be able to please all the people all the time. Not only that, your customers and their family members won't always call you to tell you what they are thinking. If what they are thinking is a negative about your agency and they have the dreaded passive aggressive gene, then it is somewhat likely that they are going to pick up the phone and not call your telephone number, but the Hotline number.
If you are accredited by ACHC, then the complaints also go to ACHC. Now there's good news and bad news about this. The good new is that ACHC:
• Will not listen to any anonymous complaints;
• Has to write up a 4 page document if they feel the complaint may be founded;
• Will have their VP review all documented complaints;
• Will not come on-site unless the complaint is about a patient safety issue; and
• Will not charge the agency for their survey for any complaint that is determined to be “not founded.”
The bad news is that if ACHC does an on-site survey and the complaint is determined to be “founded,” then your agency will be charged a day rate plus expenses for the survey. If this happens you will have to hope that ACHC has a surveyor living in the general vicinity of your office.
9. ACHC requires that every agency have a compliance program to prevent violations of the fraud and abuse laws. Some of the ways an agency must prove that they meet the standard is evidence of:
• Written policies and procedures;
• A compliance plan;
• Internal audits;
• Quality improvement activities;
• Orientation and inservice education; and
• Response to interviews.
It is permissible and not uncommon that consultants serve as compliance officers for home health agencies.
8. In the near future ACHC will require all agency personnel, whether direct or indirect employees, to have a criminal background check in their personnel file.
7. The agency must show proof of a national sex offender check on all employees providing direct patient care.
6. If your agency has any employees who routinely have someone else drive them to their visits, the agency must obtain a HIPAA agreement with those non-employee drivers.
5. The agency must show proof of each indirect employee having 8 hours of inservicing and each direct employee having 12 hours.
4. The Governing Body can be the owner in a start-up agency. And you do not have to hold a meeting with yourself.
3. In a start-up agency where the sole owner is also the entire board, no (self) written evaluation of the leader is necessary. If the agency's ownership is a 50/50 partnership, no written evaluation of the leaders is necessary.
2. With the exception of the Annual Meeting, Governing Body meetings can be held telephonically.
And the number 1 ACHC suggestion:
1. If your agency decides to buy a policy and procedure manual, (e.g. Briggs), take the plastic wrap off the manual before sending it to ACHC for approval!
ABOUT THE AUTHOR: Lynn Serra is a Senior Consultant of Beth Carpenter and Associates, a consulting firm which provides real-world expertise to improve the performance and results of home care, hospice and private duty clients. The firm has earned a reputation as a company that has deep industry experience and one that works closely with its clients to identify solutions that meet their business goals and strategic objectives. Lynn can be reached at: lserra@bethcarpenterandassociates.com.
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