Patient Care Facility Accreditation Guide

The Human Resource Standards apply to all personnel at the facility’s physical location, whether directly employed, contracted, or serving as volunteers in patient care or supporting activities. Leadership is responsible for appointing and privileging staff based on competency.

Contracted services and personnel must be managed in the same manner as direct employees and volunteers. Facility management remains ultimately accountable for contractor staff and volunteers.

HR.1

Your business must have human resource policies and procedures that address employee duties and responsibilities.

These policies must include:

1. Detailed job descriptions that list personnel qualifications and training requirements

2. Required certifications and/or licenses

3. Required experience

4. Continuing education requirements that are consistent with the items and services you provide

5. Provide copies of such policies and documents to ABC upon request.

HR.2

You must document that you have verified current licenses and certifications held by all staff members who provide patient services.

Tip

Verify the licenses and certifications held by all patient care providers annually. You can do this by contacting the issuing agency (licensure or certification board) and requesting verification that the individual’s credentials are still valid. You can do this via phone, email, or by checking the agency’s website. Once you obtain it, document the verification in the employee’s personnel file or in a separate file for this purpose. You should document the date and method by which verification was received. Use the Employee Verification form in the online Resource Kit to document your review.

HR.3

You must have orientation and training programs to familiarize all staff with your facility and procedures. This includes having appropriate reference materials and educational information available to all personnel.

Tip

You must document staff participation in initial orientation or training as well as all ongoing and remedial training programs. Documentation may include a signed, dated list of participants and a copy of the agenda for the orientation or training session.

The orientation or training should include information to ensure that your staff understands your emergency preparedness and evacuation programs and procedures. Make the orientation or training materials available to all personnel. You can make copies for each staff member or keep master copies in a location accessible to all staff.

HR.4

You must verify that your staff has completed continuing education consistent with the services and items they provide and are in compliance with their credentialing organization, as applicable.

Tip

You must document staff participation in continuing education that is relevant to their patient care duties. This continuing education may include in-service programs, manufacturer-sponsored courses, or courses provided by other sponsors. You can document participation with in-service sign-in sheets and agendas, course certificates or official continuing education statements such as those provided by ABC to credentialed individuals (MCE Statement). Keep the documentation in either in staff continuing education records or each individual member’s personnel file. Use the Assessment of Employee Continued Competency in the online Resource Kit to document your review.

HR.4.1

                                                                                                                                                                                      When required by state licensure, staff providing patient care must be licensed by the                    orthotic, prosthetic and/or pedorthic licensure body and function within their licensure                  scope of practice.

Tip

You must provide a current copy of any required state licenses. Your patient care records must indicate, with notes and signatures, that licensed staff are providing care.

HR.4.2

                                                                                                                                                                                      In the absence of state licensure requirements, staff providing custom fitted prefabricated            or custom fabricated items and services shall be certified as appropriate and function                    within the ABC Scope of Practice.

Tip

Your patient records and office policies must demonstrate that personnel providing these services are certified. You must provide copies of their current certifications. Your patient care records must indicate by notes and signatures that  the appropriate certified staff is providing care. 

HR.5

You must meet all CMS (Medicare) requirements for the items and services provided and for the employment of specialty personnel.

Tip

The business must meet all requirements described on the CMS 855S form. You must have current W-2 or 1099 forms for all staff. Maintain these forms in the personnel file or another file specific to this purpose.

HR.6

 You may privilege certified or licensed staff to provide patient care beyond their defined                 scope of practice under the supervision of a certified or licensed individual practicing within         their scope of practice. If you privilege a staff member, your process must be in compliance         with applicable laws, based on Written Objective Criteria* and under the Indirect                               Supervision* of a certified or licensed individual practicing within their scope of practice.

*See definition of Written Objective Criteria and Indirect Supervision in the ABC Scope of Practice.

Tip

Certified or licensed staff can be privileged to provide items or services beyond their scope of practice. However, you must document that you have established Written Objective Criteria to assess the competency of each person. Use the Individual Privileging Record template and the Instructions for Establishing Privileging Criteria in the online Resource Kit for help with this standard.

This documentation may take different forms, including but not limited to, proof of completion of continuing education courses related to particular devices, documented in-house or in-service training that is specific to the items or services that the patient care provider is being privileged to provide, and/or documented specific work experience participating in patient care activities.

You will need written documentation for each privileged patient care provider describing what criteria they met and how they met it. A log of items or services the individual has been privileged to provide is not considered Written Objective Criteria. The supervisor’s co-signature must appear in all patient documentation.

HR.6.1

If you utilize Support Personnel* to participate in patient care tasks related to custom fitted prefabricated or custom fabricated orthoses, prostheses and pedorthic devices, those tasks cannot include patient assessment, formulation of the treatment plan, final fitting and delivery and any follow-up care that modifies the function of the device as originally prescribed. Any tasks delegated to Support Personnel must be done under Direct Supervision*.

*See definitions of Support Personnel and Direct Supervision in the ABC Scope of Practice.

Tip

Only non-critical patient care tasks may be delegated to non-credentialed Support Personnel. The certified or licensed caregiver must be physically on-site while providing care and is responsible for documenting it in the patient’s record.

HR.7

Your delivery and set-up staff must be competent to deliver and train patients to use specialized equipment.

Tip

You must be able to demonstrate the competency of the technical personnel who deliver, set-up and train patients on specialized equipment. You must first establish Written Objective Criteria for assessing their competency. You should use the manufacturer’s guidelines for delivery and set-up in establishing your competency criteria.

Each technician should have a competency assessment document that lists each criteria measured for competency and how they were met. Tools for assessing competency may include ride-along supervision, patient satisfaction survey results, continuing education courses, manufacturer’s training courses and/ or supervised on-the-job training. Your patient records must document that delivery, setup and patient education/training have taken place. Use the Instructions for Establishing Privileging Criteria and Individual Privileging Record template in the online Resource Kit for this standard.

HR.8

You must have a policy that describes the qualifications and competencies of all staff that deliver specialized equipment, training, and home assessment.

Tip

All delivery personnel must be qualified to provide training on the delivered equipment and to perform a home assessment. You must first establish Written Objective Criteria for assessing competency as referenced in the tip for HR.8. Each individual should have a competency assessment document as referenced in the tip for HR.8.

HR.8.1

You must have a policy that lists the qualifications and competencies of the staff who train patients on the proper care, use, and maintenance of the specialized equipment provided.

Tip

Your policies and procedures must list the qualifications and competencies you require of all individuals who deliver equipment on your behalf. Written Objective Criteria and competency assessment must be established as outlined in the tip for HR.8.1. Patient records must document that patient education and training on the proper care, use and maintenance of the delivered equipment have taken place.

HR.8.2

If you provide complex rehabilitative technology, you must have at least one Rehabilitative Technology Supplier (RTS) available to service each location. In addition to the RTS, you may also employ other trained technicians to service each location. Trained Technicians must meet the requirements as defined in the DMEPOS Quality Standards.

Tip

A qualified RTS must have one of the following credentials:

• Assistive Technology Professional (ATP)
• Certified Rehabilitative Technology Supplier (CRTS)

A trained technician is identified by all of the following:

• Factory-trained by manufacturers of the products supplied by the company
• Experienced in the field of Rehabilitative Technology (e.g., on-the-job training, familiarity with rehabilitative clients, products and services)
• Complete, at least annually, ten hours of continuing education specific to Rehabilitative Technology
• Ability to program and repair sophisticated electronics associated with power wheelchairs, alternative drive controls and power seating systems

Your personnel files or other records must contain documentation of the above requirements.

HR.8.3

 If you provide respiratory equipment, supplies and/or services, you must provide services             in compliance with the current version of the American Association for Respiratory Care              Practice Guidelines.

Tip

Patient care records must demonstrate compliance with the American Association for Respiratory Care Practice Guidelines (rcjournal.com). Copies of the Guidelines must be readily available for your staff.