Mandatory accreditation by insurance companies and CMS has created a surge of interest in accreditation organizations such as the Community Health Accreditation Program.
Do you know what to prepare? When the site visitor arrives, they will begin with an inspection of your facility, go to visit customers with your staff, review patient and personnel records as well as other documentation.
Here is some insight to the process that should help you achieve a successful CHAP Accreditation:
Patient Records CHAP requires documentation of
1) customer education for each item they receive; plus a ‘leave behind’ info sheet on that product. This could be the manufacturer’s booklet if the item is new, but prepare some equipment information sheets for re-rentals like beds, wheelchairs, nebulizers and oxygen systems.
2) documentation of assessment of the patient’s home.
You can keep add simple checkboxes to one of your current forms like a delivery ticket to accomplish this documentation. You rarely need a separate new form.
Be sure one of the handouts to customers includes the Patient Rights & Responsibilities, and CHAP phone number. Consider printing this on the back of one of your current ‘leave behind’ papers.
3) If you are a respiratory provider, you need a prescription for the oxygen. A complete oxygen prescription is LITERS PER MINUTE, HOURS PER DAY, and ‘method of administration’ (usually via nasal cannula). You also need a specific MD order (in writing, for the conserver). An option is to write the liters / minute, hrs per day, and nasal cannula (and conserver, if you’re dispensing this too) in Section C of the CMN so when the MD signs the CMN, you also get a Rx. For patients already on service, consider a prescription confirmation form (faxed to MD after you complete it) for signature. Remember, RANGES are good (that is, 2-4 liters per minute, 8-24 hours per day). You’ll cut yourself a lot more leeway re: monitoring for patient compliance. Don’t forget to log the lot number of oxygen dispensed
The CHAP survey progresses from the patient home visit back to the patient file, personnel files, and equipment files.
Respiratory Equipment in customer homes:
No free standing cylinders ever, anywhere. (I can’t emphasize this enough). Systematically trigger concentrator checks. CHAP will verify that all machines are current for maintenance according to manufacturer’s guidelines. If you have one of the older oxygen analyzers, the analyzer must be calibrated each day prior to being used. Document that it was calibrated on a calibration log. Eventually, get the non-calibratable versions so you don’t have to keep the log.
Try to get in the habit of looking at ALL the equipment in the patient’s home, not just swapping out the cylinders.
The Service Tech should be routinely to be provided with information on the patient about the COMPLETE oxygen (not just the liter flow--- also the hours per minute prescribed) so that he can verify this when in the customer’s home. You also want to avoid having the Service Tech ask the patient what their Rx is, and then write it on your forms because frequently what the patient’s version doesn’t jive with the prescription you have on file from the MD. When non-compliance is discovered, PLEASE write a note indicating this fact and then re-educate the patient about how they should actually be using their oxygen. Can caregivers verbalize how to clean the nebulizer or humidifier and how frequently to do this? How often do they change the cannula? Do they know to use no more than 50 feet of extension tubing on a concentrator? Do they know the after hour number for the company?
Other DME in customer home
If they have a hospital bed and wheelchair, everything has to meet safety standards. If the patient or caregiver has re-arranged equipment since it was delivered, does the Service Tech re-educate or modify the installation so that the equipment is as safe to use as possible. The bed must have it’s plug properly installed in the ‘cheat plug adaptor’ if used. Wheel locks should be at each end on diagonal (opposite) wheels. Family should know where spare crank for bed is located. Have they called the service after hours? What was their experience?
Vehicle Inspection
The hand sanitizer must be routinely used (alcohol gel). Make sure there is a bottle in use and a spare bottle on board at any time. A Hazardous Manifest needs to be completed when oxygen is transported per Dept of Trans. Regulations. If you do use straps to hold cylinders, use non-stretch (webbing) strap to secure compressed oxygen tanks on the vehicle. EVERYTHING must be secured against movement while in transit. No exceptions.
Warehouse
CHAP wants a log of disinfecting the workbench surface every week. Have a MSDS for disinfectant and any other chemicals used by employees. You can obtain most MSDSs for any chemical used by your company from the www.hazard.com website.
‘Idiot proof’ the equipment in the warehouse. Clear identification and separation of clean/patient ready equipment, separate from dirty/contaminated equipment, separate from broken/repair equipment areas. Put up signs, (you don’t have to tape the floor areas, but can if you feel this further distinguishes one are from the other). Make it so that anyone can know the status of any and all equipment.
Label all bottles (if staff decide to decant a chemical into a generic spray bottle).
Clean off gunk first and then apply disinfectant– know how long the chemical takes to be fully effective against TB (typically is 5 or 10 minutes).
Performance Improvement
At a minimum, CHAP requires the data collection, and if possible, trending (and graphing) of:
- Incidents
- Complaints
- Customer Satisfaction
- Review of infection control logs – this means any time you have employees sick because of illness, it should be logged.
- Any time you hear about a customer illness, it should be logged.
- Periodically review these two logs for trends.
- Patient chart review for completeness & accuracy.
- Staff Turnover data
ALSO- You need to ‘benchmark (compare your performance against similar companies). Go to www.medgroup.com/wbm (winning business models) and input (for free) data about your company and get reports with graphs about how you compare.
A budget needs to exist.
CHAP standards require a drill of the emergency preparedness plan. You do need to have one annually.
Personnel Files
Staff inservices include a review MSDS, Blood-borne pathogens.
This is a list of the ‘hot issues’ which should be checked within personnel files:
- Current copy of driver's licenses (if driving to perform services)
- Current state licensure for Respiratory Therapist
- Orientation checklist completed even for staff who have been with you forever.
- Competency & Proficiency review for all direct and support patient care staff (annual).
- Performance Evaluation that corresponds to the job description. This is done annually.
- Separation of medical records (anything that notes medical findings: workmen’s comp, sick time, etc.) from clerical paperwork to comply with American Disabilities Act. (There needs to be 2 files for each employee, kept under separate lock).
- Clinical and Service Staff receive training on Blood-borne pathogens, Universal Precautions, HepB vaccination option
- Fire safety in-service to all staff
- Fire Drill
- Annual "Right to Know" training for ALL personnel (MSDS).
- Staff In-service: Review of Corporate Compliance (billing) and Patient Privacy (HIPAA) Policies
