Patient Care Facility Accreditation Guide

The Administrative Standards address the legal status and legitimacy of the business, compliance with Medicare and HIPAA requirements and establishment of the internal policies and procedures of the business. ABC awards accreditation only to a legal entity.

The Standards require that your business be legally constituted, not only in the jurisdiction in which it is based, but also in those localities in which you provide services. Full disclosure of ownership is required at the time of application and all financial records must be complete. Your business must have a physical location accessible to the public and make reasonable physical accommodations for your employees and patients. All licenses, certificates and permits must be displayed in an area accessible to the public.

In addition, written policies and procedures which address the clinical and business aspects of your business are required.

Your policies and procedures must include but are not limited to:

• Professional qualifications and continuing competency
• A mechanism to facilitate professional staff communication with the governing body
• Patient care and management, including patient and family education and patient rights
• Maintenance and confidentiality of patient records
• The protection of private healthcare information
• Patient billings, collections and complaint resolution
• Performance management
• Facility and safety management

AD.1

Your business has documentation that it is a legal entity in the state(s) in which it is located and is authorized to provide the services for which you seek accreditation.

Tip

You will need to provide legal documentation of proof of ownership, including evidence of your:

• Tax Identification Number (TIN)
• Articles of Incorporation (Corporation) or
• Articles of Organization (LLCs)

You must provide your surveyor with evidence that you have a business license and the necessary permits from federal, state and local governments. Since licensing and permit requirements vary among jurisdictions, it is critical that you contact your state and local government to determine the specific requirements for your business, such as:

• Business license from your city or county
• Zoning or occupancy permit
• Fictitious business name permit (also called dba or doing business as permit)
• Sales tax license
• Fire department permit
• Special state-issued occupational or professional licenses

AD.1.1

Your business complies with all applicable federal, state and local laws.

Tip

Some of the same issues mentioned in AD.1 apply to this standard as well. You will need to show proof of compliance with all federal, state and local laws. In states where professional licensure is required, you must provide a current copy of your valid license(s).

AD.1.2

Your business has a physical location accessible to the public.

Tip

ABC does not accredit businesses without a physical location, such as those operated by Internet or mail order. Your business must have a physical location that is accessible to the public.

AD.1.2.1

You must display all current licenses, certificates and operation permits in a location accessible to the public.

Tip

Licenses, certificates and permits must be current and displayed in an area that is accessible and viewable by your patients such as the patient waiting area, reception area or a hallway accessible to the public. Although requirements vary among jurisdictions, it is critical that you contact your state and local government to determine the specific requirements for your business, such as:

• Business license from your city or county
• Zoning or occupancy permit
• Fictitious business name permit (also called dba or doing business as permit)
• Sales tax license
• Fire department permit
• Special state-issued occupational or professional licenses

AD.2

Your business has designated at least one person who has the authority, responsibility and accountability to direct the business’s operations.

Tip

Your business must have one or more individuals who are identified as the business’s leadership. All specified individuals share the authority to direct key aspects of the business. You may identify them on business organizational charts, written job descriptions or meeting minutes.

AD.3

Your business must have a mission statement that describes the services you provide, as well as the goals and objectives of the business.

Tip

This mission statement could be part of your Policy Manual, displayed in your patient waiting area, included in your marketing/promotional materials or posted on your company website.

AD.3.1

Your business must have written policies and procedures for the performance of clinical and business operations. Your staff must be made aware and have access to current policies.

Tip

Your policies and procedures need to describe how your clinical and business activities are performed. You must inform your staff of these policies and procedures and ensure that all staff members have access to them. This information can be relayed during staff meetings and/or by providing your staff with printed or electronic copies of the policies and procedures. Staff must be notified of any changes or additions made to company policies and procedures. All changes, additions and notifications must be clearly documented.

AD.3.1.1

You must annually review your written policies and procedures for the performance of clinical and business operations. Your review must be documented.

Tip

Your documentation can be in the form of annual notes, corporate minutes, and staff meetings. This can be documented in annual notes, corporate minutes, staff meetings, policy and procedure manual.

AD.4

Your business may provide only the services and items listed on your most current ABC accreditation application.

Tip

When we review your patient charts and other records, we must be able to confirm that all services and items supplied to patients are consistent with your current ABC accreditation application.

AD.5

                                                                                                                                                                                     Your business must comply with the applicable provisions and requirements of the current           CMS DMEPOS Supplier Standards, Regulations and Medicare Contractor policies and                     articles.

Tip

You are responsible for being knowledgeable about all of the current CMS (Medicare) Supplier Standards, regulations and policies. You can read about them on the CMS website (cms.gov) or take seminars or courses to become more knowledgeable. You must disclose the current CMS Supplier Standards to your Medicare patients and have those patients provide signature of receipt. You do not have to give each patient a copy to take home but they must sign off that the standards were disclosed to them. You must have proof of your liability insurance and surety bond, if applicable. The Medicare Supplier Standards and a Patient Acknowledgement form are available in the online Resource Kit.

AD.5.1

Your business must have written policies and procedures, which require you to annually verify and document that all employees, contractors and new hires are not on the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE).

Tip

The Office of Inspector General (OIG) and ABC require health care entities to check the OIG List of Excluded Individuals and Entities (LEIE) to ensure that individuals or entities, including but not limited to employees (W-2) and contractors (1099), are not listed. Use the OIG Exclusion Checklist in the online Resource Kit to document this review.

As part of the hiring process, you must verify and document that prospective new hires are not on the OIG List of Excluded Individuals and Entities (LEIE). You must document the date of the search, the names of the individuals or contractors checked and whether the individuals or contractors were on the list.

The business must have policies and procedures in place that address the frequency of these checks and the protocol if a current employee or a prospective new hire is on the list. ABC requires that these checks be done annually and documented in your written policies and procedures.

AD.6

                                                                                                                                                                                     Your business must comply with the relevant requirements of the Health Insurance                         Portability and Accountability Act (HIPAA).                                                                                                               

Tip

The Health Insurance Portability and Accountability Act (HIPAA) has many sections and requirements. You should be knowledgeable about the Act and its applicability to your business. Make sure you stay up to date on any changes and/ or updates to HIPAA. Examples of compliance include:

• You have a designated and trained HIPAA officer
• Business Associate Agreements are in place
• Patient Acknowledgements are required and filed
• HIPAA Privacy Rules are in place
• Notice of privacy practices are displayed, distributed or accessible to patients
• HIPAA Security Regulations are in place, as applicable
• Patient records are stored appropriately
• Access to Protected Health Information (PHI) is properly restricted
• Computer and other system passwords are in place
• Documentation of staff education

Use the Patient Acknowledgement form in the online Resource Kit to document that information has been provided to patients.

AD.7

Your business must make reasonable physical accommodations for your employees and patients.

Tip

Your business must comply with applicable requirements of the Americans with Disabilities Act (ADA) ada.gov. You should seek out ways to become knowledgeable about how ADA applies to your business. You need to make reasonable physical accommodations for your employees and patients. Examples include:

• Ramps, entrances and exits must be appropriate for the business and the population of patients being served
• Patients and staff using wheelchairs, walkers, crutches or other mobility aids must be able to access the facility
• Restrooms must be accessible by your patients and staff
• Doorway width must be appropriate for your patients and staff

AD.8

Your business must have financial records that are accurate, complete, current and reflect either cash or accrual accounting practices. You must have an operating budget appropriate to your business size and scope of services.

You must maintain financial information or accounts that:

1. Manage revenues and expenses on an ongoing basis

2. Link items and supplies to the patient

3. Reconcile charges to the patient for services, items and supplies with invoices, receipts and deposits

4. Have a mechanism to track actual expenses and revenues

Tip

Accurate, complete and current financial records are an indication of the health of an organization.

Your surveyor must see evidence that:

• You have an operating budget that meets the needs of your patients and your business operations
• You manage revenues and expenses as they relate to patient services on an ongoing basis
• Your business uses either cash or accrual based accounting practices
• Your records or financial accounts allow you to identify which specific items or equipment were provided to specific patients
• Your records or financial accounts allow you to reconcile charges to patients with invoices, receipts and deposits.