NEW PATH TO ACCREDITATION

Similar documents
ACHC IS INTERNATIONAL 855-YES-ACHC ( ) I. achc.org SPRING/SUMMER 2015 ACHC CERTIFIED CONSULTANT PROGRAM

ACHC GIVES BACK! of providing the best possible experience 855-YES-ACHC ( ) I. achc.org SPRING/SUMMER 2016

The surveyor. ACHC has a new look [ ] 855-YES-ACHC ( ) I. achc.org. The Surveyor I winter 2012/2013

A YEAR OF REGULATORY CHANGE

Accreditation Commission for Health Care

DIA COMPLIANCE OVERVIEW FOR HOME HEALTH AGENCIES

Recover Health Training. Corporate Compliance Plan Code of Conduct Fraud & Abuse

Home Care Accreditation

Medicare Home Health Prospective Payment System (HHPPS) Calendar Year (CY) 2013 Final Rule

Measure Applications Partnership (MAP)

CAH PREPARATION ON-SITE VISIT

OMC Strategic Plan Final Draft. Dear Community, Working together to provide excellence in health care.

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00858

5D QAPI from an Operational Approach. Christine M. Osterberg RN BSN Senior Nursing Consultant Pathway Health Pathway Health 2013

CMS OASIS Q&As: CATEGORY 2 - COMPREHENSIVE ASSESSMENT

MHA Survey Manual: Review and Q&A

Executive Summary and A Vision for Health Care

RECENT DEVELOPMENTS 3/17/2015

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00695

Our Services Include. Our Credentials

ISDN. Over the past few years, the Office of the Inspector General. Assisting Network Members Develop and Implement Corporate Compliance Programs

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00719

CATEGORY 4 - OASIS DATA SET: FORMS and ITEMS. Category 4A - General OASIS forms questions.

Hospital Readmissions

Policies And Procedures Manual For Private Duty Non-medical Home Care

07/23/ /21/2013 (L20)

The ACHC-PCAB Pharmacy Accreditation Program

UNMC COLLEGE OF PHARMACY ADVANCED PHARMACY PRACTICE EXPERIENCE (APPE) SYLLABUS (November 2014) (Approved December 2014)

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00166

What s New with the NYS OMIG Audit Process. NYSHFA Nurse Leadership Conference April 23, Disclosure

What s Happening in the Nursing Home? Cherry Meier, RN, MSN, NHA Vice President of Public Affairs

ACCREDITATION POLICIES & PROCEDURES

5/1/2017 THE BEST DEFENSE IS A GOOD OFFENSE OBJECTIVES. Preparing for a Home Health Medicare Recertification Survey

INFORMATION ABOUT YOUR OXFORD COVERAGE REIMBURSEMENT PART I OXFORD HEALTH PLANS OXFORD HEALTH PLANS (NJ), INC.

LIMITED-SCOPE PERFORMANCE AUDIT REPORT

Organization Review Process Guide Perinatal Care Certification

State Operations Manual. Appendix M - Guidance to Surveyors: Hospice - (Rev. 1, )

STANDARDS OF CONDUCT SCH

Patient-Centered Case Management Assessment & Patient Interview Techniques

Blue Options. Health Plan Information Guide. What should I know about my benefits? What happens next? Where do I go to get assistance?

Managing employees include: Organizational structures include: Note:

Take your accreditation training to the next level

James Anderson, State Fire Marshall

Medicare Home Health Prospective Payment System

Hospital Readmissions Survival Guide

Q&A REVISED MEDICARE CoPs

AHLA. C. Great Expectations: CMS Enforcement of EMTALA. Jesse Neil Senior Operations Counsel Community Health Systems Franklin, TN

The Regulatory Focus. Critical Access Hospitals The Regulatory Process

Accountable Care in Infusion Nursing. Hudson Health Plan. Mission Statement. for all people. INS National Academy of Infusion Therapy

Chapter 4 Health Care Management Unit 5: Quality Management

PSC Certification: What really happens

Writing a Plan of Correction

MAXIMUS Webinar Series

Request for Proposal TRANSITIONAL HOUSING AUGUST 31, 2018

ABOUT FLORIDA MEDICAID

Accreditation for Your Freestanding Imaging Center. Learn why The Joint Commission compares to no other accreditor

How to Overhaul your Internal Structure to be Prepared for the New Home Health CoPs. Program Objectives

FLORIDA LICENSURE SURVEY PREP

Brenda Fischer, Unit Supervisor 09/13/2012 Colleen B. Leach, Program Specialist 09/18/2012

DM Quality Consulting, LLC

Network Participation

Facility-Based Behavioral Health Program Professional Fees Reimbursement Policy Annual Approval Date. Approved By

NURSING FACILITIES: FRIENDS OR FOES? Marie C. Berliner Joy & Young, LLP Austin, Texas (512)

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00712

CMS Hospital Discharge Planning Standards 101. Friday, March 21st, 2014

A Review of Current EMTALA and Florida Law

General Inpatient Level of Care: Managing Risks

Bon Secours Is Changing Its Approach TO ANNUAL MANDATORY TR AINING FOR NURSES

HCCA South Central Regional Annual Conference November 21, 2014 Nashville, TN. Post Acute Provider Specific Sections from OIG Work Plans

Part 1: Explanation of ALF regulatory changes as an outcome of the Florida ALF workgroup - HB 1001 Bill. Lisa Rill, Ph.D.

PADONA LTC LEADERSHIP DEVELOPMENT PROGRAM

The Monthly Publication of the National Hospice and Palliative Care Organization

HEALTH DELIVERY ORGANIZATION INFORMATION FORM

Delegation Oversight 2016 Audit Tool Credentialing and Recredentialing

Mary Heim, HPR-Social Work Specialist 09/03/2013

Revised and Amended Statement of Gina G. Greenwood, J.D. 1 Baker Donelson Bearman Caldwell and Berkowitz, PC 2

Proposed Fraud & Abuse Rule Implementing ACA Provisions. Ivy Baer October 26, 2010

Center for Clinical Standards and Quality/Survey & Certification Group

RURAL SWING BED MANAGEMENT (RSBM) TRAINING PROGRAM

Consumers at the heart of health care. 10 October 2014

Jessica Sellner, HFE, NEII 11/23/2011 Colleen B. Leach, Program Specialist 01/13/2012

2018 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc.

MEMORANDUM Texas Department of Human Services * Long Term Care/Policy

Objectives Top Ten Cited Deficiencies for Acute Care Facilities April 21, 2015

Is your Home Health Agency ready for the Final Rule to the Conditions of Participation?

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY

Akerman Practice Update

Revenue Optimization In Hospital Pharmacy Services. Presenters: Kyle Skiermont, PharmD, COO, Fairview Pharmacy Services

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY

Chapter 2 Provider Responsibilities Unit 6: Behavioral Health Care Specialists

QUALITY AND COMPLIANCE

Auditing and Monitoring Focusing Your Resources

PADONA DON CERTIFICATION PREP COURSE

The Importance of the Conditions of Participation for Hospitals

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY

Putting the Patient at the Center of Care

Integrated Licensure Background and Recommendations

4/17/2017 OBJECTIVES FEDERAL REQUIREMENTS. Having the Difficult Conversation: We need to Discharge You from Hospice

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00940

Transcription:

FALL 2013 INSIDE THIS ISSUE NEW PATH TO ACCREDITATION 3 I ACHC: A LOOK AHEAD 4 IS POTLIGHT ON THE PROVIDER MILLENIUM HOME HEALTH CARE INFUSION PLUS SINGLE-SOURCE ACCREDITATION FOR HOSPITALS WITH ANCILLARY SERVICES ACHC is pleased to announce our partnership with DNV Healthcare. The leading accreditor of US hospitals and health systems, DNV Healthcare is the only accreditation organization that integrates ISO 9001 quality compliance with the Medicare Conditions of Participation. Through this alliance, DNV and ACHC are able to offer single-source accreditation services to large hospitals and health systems seeking accreditation for both their hospital and ancillary services. REDUCING YOUR RISK ACHC HELPS YOU AVOID COSTLY SANCTIONS, SEE PAGE 5 (Continued on page 2) 6 IW ELCOME ACHC CORPORATE CUSTOMERS 7 IP ARTNER WITH ACHC 8 IP ROGRAM UPDATES 10 IU NDERSTANDING DEEMED STATUS 11 IH ME PROVIDERS CONTINUE TO DO MORE WITH LESS ACCREDITATION GUIDE TO SUCCESS SEE PAGE 12 FOR MORE INFO 13 I2 013 WORKSHOP SCHEDULE 14 IC ERTIFYING THE ACCREDITOR [ 855-YES-ACHC (855-937-2242) ] I achc.org

BOARD OF COMMISSIONERS OFFICERS Richard M. Wetherell I CHAIRPERSON VICE PRESIDENT, QUALITY, TELEFLEX MEDICAL, INC. Chris E. Clasen, BS, RRT, RCP I VICE CHAIR DIRECTOR OF THE VENTILATOR UNIT AT BLUE RIDGE HEALTH CARE CENTER Denise Fletcher, Esq I SECRETARY ATTORNEY AT BROWN & FORTUNATO Rick Ferris, RPh I TREASURER DIRECTOR OF OPERATIONS, DRUG CRAFTERS MEMBERS John Barrett SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM Regina Schaaf Dickens, EdD, LCSW RSD CONSULTING Floyd Boyer, BS, RRT, RCP EXECUTIVE DIRECTOR, NC RESPIRATORY BOARD Richard Bulich, PharmD INDEPENDENT PHARMACY CONSULTANT Barbara Stover Gingerich, RN,MS, FACHE PRESIDENT, ADVANTAGE CONSULTANTS, INC. Leonard S. Holman, Jr, RPh, CHC SEASONED HEALTH CARE ANCILLARY SERVICES EXECUTIVE AND CONSULTANT Denise Lippy VP, SYSTEMS OPERATIONS, PROTON THERAPY CENTER Susan Niewenhous, PhD, RN, CHCE, COS-C PRESIDENT, NIEW SOLUTIONS, INC. Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY Tom Tucker VP, SALES AND MARKETING, ATTENTUS MEDICAL SALES, INC. Edward Zazenski DIRECTOR OF QUALITY ASSURANCE, TELEFLEX MEDICAL, INC. Matthew Whittington BRIGADIER GENERAL, USAR (RETIRED) Marilyn Wideman, DNP, RN-BC ASSOCIATE VP OF COMMUNITY HEALTHCARE PRACTICE AT RUSH UNIVERSITY PATH TO ACCREDITATION (Continued from front cover) Our companies share a common mission, as well as philosophies about the survey process and a mutual interest in assessing the ability of organizations to deliver high-quality services. Other shared commitments include: Dedication to ISO 9001 quality compliance Providing on-site surveys that are conducted by professionals with industry-specific experience Delivering accreditation programs designed to ensure adherence to national and state regulations and requirements Creating standards for accreditation that are relevant to the services provided Offering a consultative, educational approach to the accreditation process Assessing adherence to state licensure requirements through regular, on-site surveys Our organizations are uniquely positioned to provide access to the highest quality accreditation services. For more information about this new partnership, visit us at achc.org. OUR MISSION Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services. 2 I 855-YES-ACHC (855-937-2242) I achc.org

ACHC: A LOOK AHEAD This year has brought about exciting changes for Accreditation Commission for Health Care (ACHC) with the promise of more just around the corner. We have been listening to providers for years and we continue to discover ways in which we can deliver on our mission - to provide the best possible accreditation experience to our customers and partners. José Domingos CEO CUSTOMER CENTRAL 2.0 Be on the lookout for the launch of our improved online portal - Customer Central - scheduled for release in Fall, 2013. The new version will allow providers to electronically submit applications, as well as any other documentation required to begin the accreditation process. After the on-site survey has been completed, any post-survey documentation may be uploaded to the new portal, which will instantly notify your personal Accreditation Advisor that these steps have been completed. In addition to these ease of use improvements, customers will find new webinars, podcasts and whiteboard sessions designed to provide support and information before, during and after the accreditation process. Now featuring online payment options and multimedia resources! ONLINE WORKSHOPS At ACHC, we recognize the value of ongoing education to maintain compliance following the on-site survey. This is especially critical as it gets closer to your accreditation renewal date. In an effort to support our customers, ACHC will be offering a new workshop designed for customers preparing to renew their accreditation as well as for those who may be transitioning from other Accreditation Organizations. As an added convenience, we will be hosting these workshops exclusively online. All participants will receive a program-specific Renewal Guide to Success which includes essential audit tools as well as information about the most common deficiencies and how to best prepare for the on-site survey. Be on the lookout for this exciting new series, scheduled to begin in January, 2014. As you continue your path to accreditation and strive to maintain compliance, please let us know if there is anything we can do to support you further. For more information, please contact customerservice@achc.org. ACCREDITATION COMMISSION for HEALTH CARE I 3

SPOTLIGHT ON THE PROVIDER Our accreditation experience with ACHC was definitely a positive one. Our Accreditation Advisor was very helpful during the process, answering any questions we had during the pre- and post-survey submissions. Our surveyor was professional and patient, giving us the opportunity to determine if the specific item she was looking for was truly missing. During the exit interview, she took the time to thoroughly explain her findings, and answered any questions we had. We are extremely pleased with the excellent customer service that ACHC provided from start to finish. -DEBRA GROTT Since 1994, Millenium Home Health Care has provided Medicare-certified Home Health Care services in Pennsylvania, Delaware and, most recently, has expanded into Florida. A strong commitment to providing patient-focused care and delivering quality outcomes are the foundation on which Millenium is built. Without exception, their dedication to this mission is evidenced by their high regard for compliance and program integrity. For four consecutive years, they have been named to the HomeCare Elite and have surpassed industry standards for clinical excellence, as monitored and measured by Medicare. Patients and employees are proud ambassadors of the quality services Millenium provides. Millenium had several goals which led them to initially seek accreditation. Among them was the need to meet the accreditation requirement stipulated by third-party payors as well as seeking deemed status for their Home Health programs in order to bill Medicare. By utilizing one Accreditation Organization for all nine of their locations, they have also been able to streamline practices across their facilities and realize the benefits of improved efficiencies. Choosing ACHC accreditation has its own set of benefits a dedicated Accreditation Advisor, a strong commitment to excellent customer service as well as offering the shortest timeframe for completing the accreditation process. Infusion Plus is an essential part of a diverse healthcare provider that includes Home Health, Hospice, Home Infusion, and DME services across the state of Mississippi. As a specialty pharmacy, Infusion Plus supports and serves the home health and hospice population by providing advanced knowledge of pain and symptom management, streamlining communication between Home Care nurses and Pharmacy staff, and offering the convenience of medication delivery directly to the home. By achieving ACHC accreditation, Infusion Plus has proven its dedication to providing the highest quality of patient care. ACHC s consultative approach helped Infusion Plus develop efficient policies and procedures from its beginning as a new pharmacy. We chose to use ACHC for the accreditation of Infusion Plus because they provided the best fit for our situation. The standards are extremely thorough, precise, and well-organized. We found the entire accreditation process with ACHC to be a very informative and positive experience. -INFUSION PLUS 4 I 855-YES-ACHC (855-937-2242) I achc.org

REDUCING YOUR RISK [ HOME HEALTH ] With the implementation of the first phase of CMS sanctions for Home Health providers on July 1, 2013, agencies across the country are rightfully concerned about what resources are available to help them avoid steep penalties and ensure compliance with Medicare Conditions of Participation (CoPs). With fines totaling thousands of dollars per day on the horizon, a strong compliance program achieved through earning and maintaining ACHC accreditation is a key strategy for avoiding fines that could potentially put your agency out of business. Since ACHC standards are written for providers, by providers, and are also based upon the Medicare CoPs; agencies that achieve and maintain accreditation have taken an important step in reducing their risk. In addition to the already widely-recognized benefits of accreditation, the following are examples of how ACHC will help you avoid these sanctions: All condition-level and standard-level violations cited during any on-site survey conducted by ACHC are not subject to the CMS sanctions. For providers who have deemed status, CMS only conducts on-site surveys for complaint or validation purposes, significantly limiting the risk of an on-site visit during which sanctions could be imposed. New Home Health agencies are frequently less familiar with CMS requirements. ACHC providers have access to a variety of resources, as well as a personal Accreditation Advisor and surveyors with industry-specific experience aimed at helping you before, during and after the accreditation process. ABOUT THE SANCTIONS CMS-stated sanctions are applicable in the event of a condition-level deficiency, unless the standard-level deficiency is considered to impose significant harm to an individual or if an agency has a standard-level deficiency previously found to be a conditional-level deficiency. CMS will delay the application of civil money penalties, payment suspension and the Informal Dispute Resolution (IDR) process until July 1, 2014. For more information about the CMS sanctions, read the Federal Register, Vol. 77, No. 217 published November 8, 2012. Proper education of staff is also a key component to establishing and maintaining a strong compliance program, especially as it relates to the implementation of policy in direct patient care. During your on-site accreditation survey, your surveyor will be evaluating staff providing patient care to ensure it is reflective of both professional standards of practice and agency policy. ACHC also provides audit tools to ensure compliance with essential standards related to personnel records, client charts and other required documentation and standards. EXAMPLES OF UPCOMING SANCTIONS CIVIL MONEY PENALTIES- CMS may impose a civil money penalty against an HHA for either the number of days the HHA is not in compliance or for each instance the HHA is not in compliance. Penalties can range up to $10,000 per day. SUSPENSION OF PAYMENT FOR ALL NEW ADMISSIONS- CMS may suspend payment for all new Medicare admissions regardless of whether the Condition Level deficiencies pose immediate jeopardy. EFFECTIVE DATE: JULY 1, 2014 EFFECTIVE DATE: JULY 1, 2014 A complete list of sanctions can be found at cms.gov.

WELCOME ACHC CORPORATE CUSTOMERS It is a pleasure to welcome our newest corporate customers to ACHC. We are proud to serve the accreditation needs of many of the nation s leading healthcare organizations. Our corporate accreditation process provides a flexible and cost-effective option that is ideal for national healthcare organizations. ArjoHuntleigh is a leading global provider of medical technology products and solutions for acute and long-term care needs. They are dedicated to increasing the quality and efficiency of care with solutions aimed at actively preventing the most common healthcare-related incidents. Numotion was formed by the merger of two leading providers of custom mobility products; ATG Rehab and United Seating & Mobility. Both companies had previously been accredited by ACHC and bring more than 40 years of combined industry experience to the new company. ACHC is proud to serve the accreditation needs of Numotion as it looks to the future. Personal Touch Home Care, Inc. began operations in 1974 and has since grown into a national company with more than 50 locations in 13 states. They provide quality in-home services designed to assist patients with health-related tasks and activities of daily living. For more information about ACHC s Corporate Accreditation Process, please contact Roy Bigler rbigler@achc.org or (855) 937-2242. 6 I 855-YES-ACHC (855-937-2242) I achc.org

PARTNER WITH ACHC THANK YOU TO OUR VALUED PARTNERS Provide your members and customers with the best choice in accreditation with the ACHC Preferred Partner Program. Offered to national associations, state associations and other group member organizations, partnering with ACHC provides your members with significant benefits while encouraging provider engagement with your organization. Associations and member organizations also receive financial support to help cover any costs incurred while promoting ACHC to members as well as the opportunity to expand their reach to potential members. At ACHC, we are committed to offering accreditation services, educational support and quality customer services to all of our partner organizations, said Matt Hughes, Director of Business Development and Customer Service. We believe providers are well-served by the many benefits gained through association membership and, to the extent that we can assist accredited organizations with accessing those resources, we are eager to play a role. BENEFITS FOR YOUR ORGANIZATION Press release announcing partnership distributed nationally Promotion for organization on achc.org and inclusion in The Surveyor ACHC list of customers for your state provided annually Opportunities to collaborate on communications to targeted audiences BENEFITS FOR YOUR MEMBERS Educational opportunities, including discounted workshop rates and free webinars Customized accreditation workshops provided by ACHC for your members Cost savings on accreditation For more information on the Preferred Partnership program, please contact Lindsey Holder lholder@achc.org or (855) 937-2242. Our agreement with ACHC provides a positive benefit for our association and members. ACHC is a credible organization in our industry and we support their initiative to drive additional resources to state associations. BOBBY HORTON, EXECUTIVE DIRECTOR OF SCMESA CONVENIENT CARE ACCREDITATION ACHC is now seeking beta test sites for its accreditation program for Convenient Care. If interested, please email Julie Pazun, Director, Home Health, Hospice, Private Duty, Behavioral Health & Convenient Care at jpazun@achc.org. I 7

PROGRAM UPDATES [ HOME HEALTH ] The Centers for Medicare and Medicaid Services (CMS) recently stated that the Home Health & Hospice Aide Plans of Care CANNOT use PRN or per patient request for ANY task, whether specifying personal care or non-personal care. Use of PRN or per patient request in a patient record must be cited as a deficiency during an on-site survey. Multiple types of care can only be used when it has been documented by the nurse that the patient/caregiver has the ability to functionally and cognitively make the choice. Aide Plans of Care must be individualized and refrain from using blanket statements like patient is cognitively and functionally able to make the choice for all patients and tasks. If patients are requesting a specific type of care as a result of changes in their condition, Aides must still contact their supervisor prior to administering care. For additional information about this update please see achc.org/cms. [ HOSPICE ] The 2013 work plan released by the Office of the Inspector General (OIG) highlights two areas of focus to reduce fraudulent or inappropriate claims: Marketing practice and financial relationships with nursing facilities The OIG recently found that 82% of hospice claims for beneficiaries in nursing facilities did not meet Medicare coverage requirements. Accordingly, hospice facilities with a high census of patients whose care is provided in a nursing facility will be under close scrutiny. General Inpatient Level of Care The OIG reports that 27% of hospice organizations billing Medicare did not meet the Condition of Participation mandating that this type of care be provided. The OIG will be scrutinizing the appropriateness of hospice General Inpatient Level of Care claims. [ PRIVATE DUTY ] MANDATORY ACCREDITATION FOR NC PRIVATE DUTY PROVIDERS By June 1, 2014 all Private Duty agencies providing skilled nursing services must be accredited to be in compliance with Clinical Coverage Policy No. 3G issued by the North Carolina Division of Medical Assistance for Private Duty Nursing. To assist NC Private Duty agencies in meeting this deadline, ACHC is offering a modified accreditation process to North Carolina agencies who fall under the guidelines of this new policy. To expedite the accreditation process, NC Private Duty agencies are not required to submit a Preliminary Evidence Report (PER) to ACHC. All agencies are still required to have all of the policies and procedures typically included in the PER; however, it is not required that these be submitted prior to the on-site survey. By waiving this requirement, an agency is only required to submit an application (indicating a survey readiness date) and deposit to begin the accreditation process. The survey readiness date only provides that an unannounced, on-site survey will not happen prior to that date. For more information on this policy, contact Mary Kane Ziegler at mziegler@achc.org or (855) 937-2242. 8 I 855-YES-ACHC (855-937-2242) I achc.org

[ SLEEP ] ACHC released new Home Sleep Testing standards to provide a stand-alone accreditation option for polysomnography services that are conducted in the home setting. Many providers are offering sleep testing services in the home setting in an effort to comply with payor requirements and provide increased access for patients with obstructive sleep apnea. By developing standards specifically for providers of home sleep testing services, our goal is to help improve the quality of patient care through standards that align with national compliance and industry best practices. ACHC also offers full Sleep Lab accreditation for sleep testing services conducted in independent diagnostic, hospital, physician, or home-based testing facilities. Providers that achieve ACHC Sleep Lab accreditation will also include the home sleep testing component. [ PHARMACY ] Long Term Care Pharmacies (LTCs) face a unique set of challenges compared with traditional retail pharmacies. Demographic trends project a strong demand for Long Term Care Pharmacies over the next 20 years. Though currently not a requirement, this projected increase in pharmacy spend by federal and private payors may lead to increased oversight or accreditation requirements. ACHC has developed standards specific to LTCs to help them continue to provide the highest quality services in an efficient manner throughout this projected growth. ACHC Infusion Pharmacy standards have always included compliance with USP 797 for sterile compounding. During 2013, we will also be releasing stand-alone standards for sterile compounding that are compliant with USP 797 as well as standards for non-sterile compounding that are compliant with USP 795. [ BEHAVIORAL HEALTH ] ACHC offers accreditation for Psychiatric Home Care specifically created for Home Health agencies providing this specialty service. Psychiatric Home Care, also referred to as Behavioral Health Home Care, integrates behavioral health interventions into home care services for patients whose mental illness, substance abuse or intellectual/development disabilities make it difficult or otherwise prevent them from receiving care outside of their homes. Services are provided by a psychiatric nurse and other home care personnel, as ordered by a physician. Psychiatric Home Care may be included as a specialty service for providers seeking ACHC accreditation for Home Health. For Home Health agencies already accredited by ACHC, we recommend adding this specialty service during your accreditation renewal process. Amedisys Home Health strives to lead innovation and advancement of behavioral health services across the nation. Accreditation helps us ensure that we remain on the leading edge of innovation and quality care. Meeting these standards provides worthy goals for which to strive at every care center. Elizabeth C. Gregory PhD, RN,CNS, LPC Director of Behavioral Health Amedisys Home Health [ DMEPOS ] Sensitive to the ongoing regulatory challenges faced by healthcare providers, ACHC has introduced three payment options for DMEPOS, Pharmacy and Sleep accreditation. These were developed to help providers manage their cash flow by spreading the cost of accreditation over several payments. For more information on Psychiatric Home Care, contact Behavioral Health Clinical Manager, Britt Welch, MS, LPA bwelch@achc.org or (855) 937-2242. ACHC successfully released its new Transition Program in 2012. The program was created to provide currently-accredited organizations the opportunity to switch to ACHC accreditation, regardless of where they are in their current accreditation cycle. In fact, many providers have realized greater benefits and savings by transitioning with more than one year remaining until renewal. The process is streamlined to be as seamless and efficient as possible. For more information about ACHC s Transition Program, please contact our Transition Coordinator, Lindsey Holder, at transition@achc.org. For questions about ACHC s Program Updates, please contact Kevin O Connell koconnell@achc.org. ACCREDITATION COMMISSION FOR HEALTH CARE I 9

UNDERSTANDING DEEMED STATUS By Lisa Meadows, ACHC Clinical Educator for Home Health, Hospice and Private Duty Providers wanting to bill Medicare for the services they offer must first obtain a Medicare provider number. To do so, an initial Medicare certification survey must be conducted by either the state authority or through an Accreditation Organization that has deeming authority granted by the Centers for Medicare and Medicaid Services (CMS). YOUR ACHC EXPERTS! OUR CONSULTANTS ARE CURRENT AND FORMER ACHC SURVEYORS WHO KNOW WHAT YOU NEED TO GET THE JOB DONE! We are able to help you with your start-up or your ongoing needs: Mock Surveys, Policy Manuals, Quality Improvement OASIS Review/Coding Services by Coding-certified RNs Educational Webinars and much more For state authorities, these initial Medicare certification surveys are designated as Tier IV the lowest priority for survey scheduling and completion. Often, providers choosing this option wait several years before receiving an on-site survey. Until the survey is successfully completed, an organization is unable to bill Medicare for the services provided. The solution to expediting this process is to seek accreditation with a national Accreditation Organization such as ACHC. ACHC has deeming authority for Home Health, Hospice and DMEPOS and is able to conduct initial Medicare surveys within 120 days of receiving your application. During a deemed status survey, ACHC will perform a survey to determine compliance with the Medicare Conditions of Participation (CoPs). Home Health and Hospice agencies that choose a deemed status survey will remain under the jurisdiction of ACHC for oversight of ongoing compliance. For Providers Seeking a Medicare Provider Number: To ensure you are scheduled for a deemed status survey, your application should indicate that you are seeking an initial Medicare survey AND that you are requesting a deemed status survey. For Providers with a Medicare Provider Number: If you wish to seek Medicare recertification through ACHC, your application should indicate that you are requesting a deemed status survey. CONTACT THE CONSULTANTS WHO KNOW WHAT YOU NEED TO BE COMPLIANT AND SUCCESSFUL! (866) 428-4040 I www.5starconsultants.net info@5startconsultants.net For more info on deemed and non-deemed surveys, please contact your ACHC Accreditation Advisor or e-mail us at customerservice@achc.org. 10 I 855-YES-ACHC (855-937-2242) I achc.org

HME PROVIDERS CONTINUE TO DO MORE WITH LESS By Greg Stowell, ACHC Clinical Compliance Educator for DMEPOS, Pharmacy & Sleep The HME industry has reached a point that has many providers asking, Are we there yet? Have recent changes to reimbursement protocols and beneficiary access to services placed the provision of quality products and services at risk? Is this the time that many feared would come, where the high quality of products and services can t be maintained? Most of our HME providers entered the industry with a sincere desire to serve clients with the highest level of products and services. This is reflected in their mission statements and their commitment to patients through policies, procedures, and staff. Providers simply cannot allow quality to become the latest casualty of the rapidlychanging HME industry. ACHC standards, along with your organization s compliance through relevant and realistic policies and procedures, offer many quality and operational efficiencies that can help you maintain the high level of products and services your customers demand. HERE ARE SOME WAYS YOU CAN LEVERAGE ACCREDITATION STANDARDS FOR MAXIMUM BENEFIT: 1 2 3 4 Ensure that your daily operations match your policies and procedures (P&Ps). Update your P&Ps annually and involve your staff in suggesting changes. Know exactly what ACHC standards require (and do not require) to avoid committing valuable company resources based on misinterpretation. Speak with your Accreditation Advisor, Department Director, or Clinical Educator to receive clarification on standards. Think outside of the box; not just in the products you offer, but the processes and procedures you follow. Examine each step of your process from order entry to final pickup for opportunities to improve efficiency. Leverage technology and monitor your business efficiencies with measurable data. There has never been a more important time to connect with others in the industry. Network with other providers through state associations, trade organizations, and shows to learn about new strategies for success. Attend an ACHC workshop as a great way to connect with other providers and ask specific questions about your business. For more information, please contact Greg Stowell at gstowell@achc.org. VISIT BOOTH #734 AT: Orlando, FL I October 8-10, 2013 I 11

ACHC ACCREDITATION GUIDE TO SUCCESS The ACHC Accreditation Guide to Success is a program-specific workbook developed to guide you through every step of the accreditation process. This comprehensive resource includes: Explanation of each Accreditation Standard Compliance Checklists Personnel Chart Audit Tools Patient Record Review Assessments Potential Interview Questions Best Practices for a Successful On-site Survey AVAILABLE FOR HOME HEALTH DMEPOS HOSPICE PRIVATE DUTY PHARMACY Coming Soon! All participants of ACHC Achieving Accreditation workshops receive a complimentary ACHC Accreditation Guide to Success. Visit the Resources tab at achc.org to learn more or to order today. MULTIMEDIA New blogs, podcasts and whiteboard sessions will be released bi-monthly and cover a variety of topics such as healthcare reform, tips on accreditation, top deficiencies found during on-site surveys and continued compliance. ACHC is committed to developing current, interesting and, most importantly, relevant content for our customers to learn about the accreditation process and understand how regulatory issues and a changing healthcare environment will affect their day-to-day operations. New posts will be announced on our social media pages and our blog. WEBINARS Affordable webinars for renewing ACHC accreditation or transitioning to ACHC in Home Health, Hospice and Private Duty will debut in 2014. All participants will receive the ACHC Accreditation Renewal Guide to Success workbook, created specifically for the reaccreditation or transition process. 12 I 855-YES-ACHC (855-937-2242) I achc.org

UPCOMING WORKSHOP: PHARMACY: ACHIEVING ACHC ACCREDITATION November 14 I Cary, NC UPCOMING WORKSHOPS ACHC has developed program-specific workshops to assist in the smoothest accreditation experience possible. Learn how to prepare a Plan of Correction, and the development of Policies and Procedures. All curriculum is based on the ACHC Accreditation Guide to Success. I participated in this workshop and it was worth every penny. The workbook alone was perfect as my agency attempts to line everything up for accreditation. You can t go wrong, in my opinion. I learned so much from their speakers. Workshop Attendee ACHIEVING ACHC ACCREDITATION HELPING YOU THROUGH THE ACCREDITATION PROCESS OCTOBER SUN MON TUE WED THU FRI SAT NOVEMBER SUN MON TUE WED THU FRI SAT PHARMACY November 14, 2013 Cary, NC PRIVATE DUTY January 14, 2014 Cary, NC 6 7 1 8 2 9 3 10 4 11 5 12 3 4 5 6 7 1 8 2 9 13 14 15 16 17 18 19 10 11 12 13 14 15 16 20 21 22 23 24 25 26 17 18 19 20 21 22 23 27 28 29 30 31 24 25 26 27 28 29 30 ACADEMY FOR PRIVATE DUTY HOME CARE: SERVING MORE CLIENTS PRESENTED BY STEPHEN TWEED, THE CEO OF LEADING HOME CARE PRIVATE DUTY October 25 Cary, NC Participants will learn: The top marketing techniques in Home Care The differences between consumer and referral marketing The most effective marketing strategy for your business How to turn inquiries and referrals into admissions $250 OFF ACCREDITATION FEES AND FREE ACHC ACCREDITATION GUIDE TO SUCCESS when you attend an ACHC workshop! TAKEN OFF AT CHECKOUT No one else in the industry has the information that you will gain when you come to this unique, high-impact learning program. Not only will you get the benefit of the information provided by our faculty, but you ll have the opportunity to network and exchange ideas with other successful private duty business owners. ACCREDITATION COMMISSION for HEALTH CARE I 13

CERTIFYING THE ACCREDITOR By Barb Sylvester, VP of Clinical Compliance, Regulatory Affairs and Quality The International Organization for Standardization (ISO) develops international quality standards through global consensus which provide state-of-the-art specifications. ISO has developed more than 19,500 international standards covering almost all aspects of technology and business ranging from food safety to computers and from agriculture to healthcare. 1 Since 2004, ACHC has committed to maintain its own quality management system to ISO standards to ensure our superior performance provides the best possible experience for our customers. ACHC maintains its ISO 9001:2008 certification by successfully undergoing an annual on-site survey and evaluation. Similar to what our customers experience, ACHC also participates in self-audits, mandatory trainings and other essential activities in preparing for an on-site survey. Our team is equally concerned with the credentials of the surveyor, expecting that he/she will conduct an objective, accurate survey and provide insights into best practices that will enhance operational processes or improve customer satisfaction. When necessary, we make recommended adjustments and submit evidence of corrective actions to our Accreditation Organization for approval. We are pleased to announce that we successfully achieved a 3-year ISO 9001:2008 certification as of August 14, 2013. 1 Retrieved from www.iso.org/iso/home/about.htm on July 16, 2013. Both ACHC and ISO developed standards which can be used as strategic tools to: Ensure compliance with applicable statutory and regulatory requirements Recognize the importance of following processes to ensure consistency Specify the importance of documentation requirements Focus on measurement and analysis Provide a process for continual improvement Evaluate the effectiveness of an organization Reduce costs by minimizing waste and errors Enhance customer satisfaction ADVERTISE IN OUR UPCOMING EDITIONS National circulation of more than 20,000 issues Exposure to ACHC-accredited customers, associations, publishers, providers, consultants, and government agencies Reasonable rates and additional online advertising contact marketing@achc.org 14 I 855-YES-ACHC (855-937-2242) I achc.org

ACHC S TRANSITION PROGRAM A BRIGHTER SIDE TO ACCREDITATION visit achc.org/transition Build organizational strength Scan or Click to Learn More. corridorgroup.com 866-263-3795 Survey Prep Accreditation Resources Manuals & Tools

ISO 9001:2008 Certified CMS Approved FOR PROVIDERS. BY PROVIDERS. 139 Weston Oaks Ct. Cary, NC 27513 achc.org EDUCATIONAL RESOURCES [ AT YOUR FINGERTIPS ] ACCREDITATION GUIDE TO SUCCESS ACHC WORKSHOPS CUSTOMER CENTRAL 2.0 www.achc.org