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.

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

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 and comply with all applicable federal, state, and local laws.

Tip

Provide legal documentation of ownership, including Tax Identification Number, Articles of Incorporation or Articles of Organization. Provide evidence of applicable business licenses and permits.

AD.1.1

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

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

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.2

Your business has designated at least one person who has the authority, responsibility and accountability to direct the business’ 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 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.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 all applicable CMS DMEPOS Supplier Standards, DMEPOS Quality Standards, Medicare statutes and regulations, CMS Publication 100-08, Medicare Program Integrity Manual, and applicable Medicare Administrative Contractor policies and articles. This includes compliance with Social Security Act § 1834(j), including the requirement to maintain Medicare supplier enrollment and billing privileges, if applicable; 42 CFR §§ 420.201–420.206, including disclosure of applicable direct and indirect ownership and control interests; and 42 CFR § 424.57, including all applicable DMEPOS supplier standards and enrollment requirements.

The business must maintain accurate and current ownership, control, enrollment, and operational information and timely report ownership, control, or other material changes as required by CMS and the applicable Medicare contractor.

Tip

You are responsible for being knowledgeable about all 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 that 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 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