Annual ACHC Standard Updates

On an annual basis, ACHC reviews the standards for each accreditation program to ensure relevancy. Generally the revisions are minor and include additions, deletions, and clarifications. The 2019 revisions were released February 1. All deletions and clarifications became effective February 1. New standards and additions to standards become effective June 1.

Below is a partial list of revisions, by program:

Home Health

Standard  Change Effective Date
HH1-8A Added the word organization/organizations to the standard regarding the written agreement requirements. February 1, 2019
HH2-6B.02 Clarified in the standard that a written policy and procedure regarding providing the patient with information about advance directives. February 1, 2019
HH4-1B.01 Clarified direct patient care to be the care of a patient provided personally by a staff member or contracted individual/organization in a patient’s residence or healthcare facility. Direct patient care may involve any aspects of the health care of a patient, including treatments, counseling, self-care, patient education, and administration of medication. February 1, 2019
HH4-2H.01 Replaced the word “contact” with “care” as it related to criminal background checks. February 1, 2019

Hospice

Standard  Change Effective Date
HSP1-8A Added the word organization/organizations to the standard to be consistent with the Medicare Conditions of Participation §418.100(e) regarding the written agreement requirements. February 1, 2019
HSP4-1B.01 Clarified direct patient care to be the care of a patient provided personally by a staff member or contracted individual/organization in a patient’s residence or healthcare facility. Direct patient care may involve any aspects of the health care of a patient, including treatments, counseling, self-care, patient education, and administration of medication. February 1, 2019
HSP4-2H Replaced the word “contact” with “care” as it related to criminal background checks. February 1, 2019
HSP4-14A Added physician assistants as an allowable individual that the interdisciplinary group may confer with regarding the patient’s medication management. February 1, 2019
HSP5-1B Decreased the retention of medical records to six years from the date of the most recent discharge of death of the patient from seven years. February 1, 2019
HSP6-3A Removed the requirement that the annual QAPI report is included in the hospice’s annual evaluation. February 1, 2019
HSP7-4F Changed the Hospice standards referenced in the interpretation to the correct Hospice standards; HSP7-3A to HSP7-4B, HSP7-3B to HSP7-4C, HSP7-3C toHSP7-4D, and HSP7-3D to HSP7-4E, respectively. February 1, 2019

Private Duty

Standard  Change Effective Date
HH1-8A Added the word organization/organizations to the standard regarding the written agreement requirements. February 1, 2019
HH2-6B.02 Clarified in the standard that a written policy and procedure regarding providing the patient with information about advance directives. February 1, 2019
HH4-1B.01 Clarified direct patient care to be the care of a patient provided personally by a staff member or contracted individual/organization in a patient’s residence or healthcare facility. Direct patient care may involve any aspects of the health care of a patient, including treatments, counseling, self-care, patient education, and administration of medication. February 1, 2019
HH4-2H.01 Replaced the word “contact” with “care” as it related to criminal background checks. February 1, 2019

DMEPOS

 Standard Change Effective Date
 DRX3-4B Added clarification regarding the requirements for notifying clients/patients of their financial responsibilities  February 1, 2019
 DRX4-7A Added requirement for annual competency assessment to be conducted for personnel who clean, test and/or repair equipment  June 1, 2019

Pharmacy

Standard Change Effective Date
 DRX3-4B Added clarification regarding the requirements for notifying clients/patients of their financial responsibilities  February 1, 2019
DRX7-8J.01 New standard for IRX, SRX, and SRXOnly that adds quality control measures to assure proper medication labeling  June 1, 2019

Sleep

Standard Change Effective Date
SLC4-6A Added clarification that all technicians scoring sleep studies must be credentialed as required by standard  February 1, 2019

PCAB

Standard Change Effective Date
TCRX7-A & B Changed the requirement for the submission of continued compliance data from annual submission to submission during the mid-point in the accreditation cycle  June 1, 2019

ACHC has posted a complete list of updated standards, for each program, in the 2019 Standards Update Reference Guides. Access the Standards Update Reference Guides in your Customer Central account by selecting the “Resources” tab, then choosing the “Education Library” dropdown, then choosing your program within the “Educational Tools” section, and then clicking on the 2019 update.

If you have any questions regarding these changes, please contact your Account Advisor.

Mapping Community Palliative Care

Palliative care is well established in U.S hospitals, with seventy-five percent of those with fifty beds or more reporting a palliative care program. Recognizing the needs of seriously ill patients and their families in all care settings, many palliative care programs are working to extend services in their communities – either by expanding existing hospital programs to other settings, or building new programs in non-hospital settings.  These programs provide palliative care in patient’s homes, nursing homes, doctor’s offices, and outpatient clinics, and are vital in reaching a patient population that would otherwise not be served through traditional hospital palliative care. However, little is known about the locations or extent of this community reach, or how these community palliative care services are staffed and structured to meet patient and family need.

To fill this gap, the Center to Advance Palliative Care (CAPC), in collaboration with the National Coalition for Hospice and Palliative Care (NCHPC), launched Mapping Community Palliative Care.  The goal of this initiative is to develop a comprehensive inventory of community palliative care programs and estimate their prevalence nationwide.

The three-year project, funded by the Gordon and Betty Moore Foundation, will catalog palliative care programs in the community and analyze palliative care access across settings. By completing a short eight-question survey, community palliative care programs nationwide can put their program “on the map,” identifying themselves, where their services are provided, and what services they offer. Mapping Community Palliative Care is committed to increasing access to palliative care services for patients, families, caregivers, and providers. Programs participating in Mapping Community Palliative Care will have the option to be listed in the Provider Directory on GetPalliativeCare.org, the leading online resource for palliative care information for people with serious illness and their families. Anyone looking for palliative care resources will be able to search the directory by location and service type (hospital, home, nursing home, and office/clinic). As more and more programs add their profiles to the directory, patients and families will be able to find local resources and programs to meet their specific needs.

Mapping participants are also invited to participate in the National Palliative Care Registry™ – by providing annual aggregate data on program structure and operations, participants receive reports comparing their palliative care programs to their peers. Mapping Community Palliative Care and the National Palliative Care Registry™ are both free and open to programs across all care settings.

Mapping Community Palliative Care is working to bring the field of palliative care one step closer to a comprehensive national profile of palliative care services across care settings.

To participate, please visit mapping.capc.org and “make your mark” today!

If you are interested in learning more about Mapping Community Palliative Care, please contact Rachael Heitner, MA, CHPCA, Research Associate at CAPC, at mapping@capc.org.

National Home Care & Hospice Month – Stories from Hospice in the Pines’ We Honor Veterans Program

November is National Home Care & Hospice Month, and the National Hospice and Palliative Care Organization’s (NHPCO) theme for this year is “It’s about how you live!”

ACHC asked agencies to submit stories honoring the lives of the patients they serve. We are excited to share two stories we received from Hospice in the Pines in Lufkin Texas. These two stories are about men this organization serves through their We Honor Veterans program. This program was founded by the National Hospice and Palliative Care Organization in collaboration with the Department of Veteran Affairs that partners with hospice organizations around the nation. We are proud of Hospice of the Pines’ commitment to our veterans and the way they honor the lives of these heroes!

 

Bill Fortune

At 91 years old, Colonel Bill Fortune is an exceptional American hero who served in the United States Air Force during World War II.

This impressive and decorated serviceman is one of two siblings in his family to serve in the United States Military. Collectively his immediate family members and himself have served a total of over 120 years in the military.  Colonel Bill Fortune was one of the first air pilots to fly into an active hurricane.

Today he displays several pictures within his bedroom, above his bed, of the B-29 airplanes which he flew in the war. These images bring such great joy to his mind and heart when reminisced upon. Colonel Fortune was a co-pilot, and served for a total number of 36 years in the United States Military.  Colonel Bill Fortune is a native of Lufkin and has been active until his diagnosis with cancer, yet his lovely and beautiful spirit truly remains ever cheerful to all.

Hospice in the Pines had the honor of recognizing his dedicated service through the We Honor Veterans pinning ceremony. On Friday September 15, 2017, three team members from Hospice in the Pines joined the Fortune family in their home to celebrate the life and servitude of Colonel Fortune. It was a ceremony that doubled as a small family reunion and will forever be a memory in the legacy of Colonel Fortune’s beautiful life. What an honor it was to play a part in showing appreciation to such a dedicated veteran.

 

Tommy Solomon

Tommy Solomon is a United States Veteran who served during the Vietnam War.

Mr. Solomon was stationed in Lackland Airforce Base, he was selected to be a mechanic for his expertise and knowledge of repairing and assembling airplanes. In Mr. Solomon’s home, you will find numerous models of planes decorated with the traditional colors of the F104-Fighter planes and the Douglas DC3 planes, all which Mr. Solomon had assembled, dissembled, fixed, cleaned. Mr. Solomon worked on planes such as the C124, C118, P38 Fighter, and the C121 which he stated, “this was the most beautiful plane ever built”. Mr. Solomon said he will never forget his fellow comrades and the unification they all shared to take care of one another; to always provide servitude, dignity, shared values and most importantly faith and unity with one another.

Mr. Solomon’s spirit, strength and humor can still be felt and seen every day. His art and Greek mythological statues and images that can be found in his home, remind him of living in Greece for a short duration of his life.  Mr. Solomon loves to spend his time with his family and his many pets.

Hospice in the Pines was honored to acknowledge his service to our country through the We Honor Veterans pinning ceremony. Mr. Solomon’s dedicated service is a glimpse at the wonderful and beautiful life he has lived. We are forever grateful for his service.

National Home Care & Hospice Month – Share Your Story with ACHC!

November is National Home Care & Hospice Month, and the National Hospice and Palliative Care Organization’s (NHPCO) theme for this year is “It’s about how you live!”

ACHC wants to hear how your agency lives out this motto! Help us raise awareness about home care and hospice services by sharing an example of how you help your patients achieve a better quality of life. Email us your story at ainfo@achc.org, comment on our Facebook page, or tag us on Twitter.

At the end of the month we will select one participating agency to win a $50 Starbucks gift card! We will also be featuring your stories on the ACHC Blog, social media, and in the ACHC Today e-newsletter.

If you are looking for ways to celebrate and raise awareness about home care and hospice services this month, check out the National Association for Home Care and Hospice (NAHC) list of Celebration Ideas.

In this season of thanksgiving, we want you to know how grateful we are for the high-quality care you bring to your patients. We are truly blessed to be your accreditation partner!

Are You in Compliance with Emergency Preparedness Requirements?

On September 8, 2016, the Federal Register posted the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Healthcare providers and suppliers affected by this rule must comply with and implement all regulations by November 15, 2017.

These Emergency Preparedness regulations have been incorporated into the Home Health Conditions of Participation (CoPs) and the Hospice requirements are in the State Operations Manual, Appendix Z- Emergency Preparedness for All Providers and Certified Supplier Types, Interpretive Guidance. ACHC recently received approval from the Centers for Medicare & Medicaid Services (CMS) for the revised ACHC Accreditation Standards that incorporate the new Emergency Preparedness requirements. These new standards are available to download on Customer Central.

You can view the interpretive guidelines and valuable resources to assist with developing your agency’s Emergency Preparedness Plan online.

ACHC has developed several educational resources to help you prepare for compliance with Emergency Preparedness Conditions of Participation:

Customer Central

DYK Educational Emails

Accreditation University

An Interview with the 1st Provider to Achieve ACHC Distinction in Palliative Care

ACHC Distinction in Palliative Care

This spring, Mountain Valley Hospice & Palliative Care became the first provider to achieve Accreditation Commission for Health Care’s newly launched Distinction in Palliative Care. For Denise Watson, MVHPC executive director, distinction has made a world of difference.

MVHPC, which has been ACHC-accredited for hospice since 2007, began providing palliative care services about five years ago. In late 2015, ACHC invited MVHPC to join a team – facilitated by Judi Lund Person of the National Hospice and Palliative Care Organization – that helped to develop ACHC’s Palliative Care Standards based on the National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care. In early 2017, MVHPC served as ACHC’s beta test site for those standards, undergoing a survey and ultimately earning the distinction. It was an experience that Watson says helped to make MVHPC’s palliative care program stronger and more structured, and that put the organization “a step above.”

ACHC followed up with Watson to learn more about MVHPC’s experience.

ACHC: Talk about your experience incorporating the ACHC standards into your practice.

DENISE WATSON: I put a team together with some of our top leadership and our medical director and our practitioners, and we started reviewing our (palliative care) policies and comparing what was lacking and where we did not meet the standards. We found we had a lot of work to do. So we went standard by standard to make sure that we had a policy. And we of course had to educate the practitioners and everybody that was a part of the program on what they had to do, because it was additional work, additional assessments. So it was a transition of changing a lot of the way we were doing things.

ACHC: What was an area in which you found your agency needed work?

DW: We didn’t really have any formal policies related to the interdisciplinary team. We were meeting once a month, roughly. We had to change the time and make it regular and really focus on that team care as opposed to just “here’s a referral; the nurse practitioner needs to see them.” So there was more structure and they had to follow certain policies and standards and processes that we were really very vague before.

ACHC: How did ACHC work with you to amend the standards based on your feedback?

DW: I really appreciate the fact that ACHC was open to listening to how the standards worked for us, per se, by changing policies and our processes. It was nice to know that we were part of making sure that we didn’t have overkill on the standards or maybe we didn’t have them strong enough. There was some movement there and flexibility that we could all come to an agreement, especially around the comprehensive assessment. Sometimes there’s a “one and done visit” and you never see (the patient) again, so we had to take that into account. Palliative Care, it’s different from hospice.

For example, with hospice there’s a comprehensive assessment for the nurse, chaplain, social worker. The issue is when our practitioners go out there to do the (palliative care) assessment, they have to ask questions about psychosocial; it’s all embedded in all these comprehensive assessments. What we elected to do is to have them ask a couple of simple questions. If they identify from those questions a need for spiritual or psychosocial assistance, then they make the referral to that discipline to do all those questions. What we were trying to do was limit the amount of detailed information a nurse practitioner or a physician had to get.

ACHC: Can you comment further on how does palliative differs from hospice?

DW: In Palliative Care, you’re focusing on a symptom, e.g. pain management. In hospice you’re focusing on all kinds of symptoms.

Hospice is much more intensive. You’re really supporting the entire family. We’ve tried to bring that into palliative care, but these patients are mobile. You may not have the family at the bedside. 60-70 percent of our patients in palliative care end up coming to hospice. You bring that interdisciplinary piece to it, but it’s not as involved. You’re focusing on that symptom, and you may find other stuff when you get in there, e.g. they need emotional support.

ACHC: How has MVHPC most benefitted from having achieved the Distinction in Palliative Care?

DW: We had tried, the entire time we were doing palliative care, to make our program structured. But we were lacking in structure and lacking in everybody knowing what they really should capture in a visit and then how they bring this back and share what they’re doing as a team, and then really talk as a team about goals of care.

It was fragmented, in my opinion, and this really brought structure to our program. And it made us do stuff that we had wanted to do, or had intended to do, forever. Our policies were very vague. It forced us to really put structure and meat to the program.

“I feel like our program is just much more structured. Everybody’s on the same page. It has been beneficial for us, for sure.”

ACHC: What does acheiving the ACHC Distinction in Palliative Care mean to you?

DW: It means we have taken the extra step to ensure our program provides quality service. We are taking steps that we didn’t have to do to improve our program. I think it says that we are doing this for the right reasons. The ultimate goal is to provide the best care to these patients. It’s a sense that somebody’s looking over our shoulder. Somebody’s looked at our program. Somebody has said, “You’re doing what you’re supposed to be doing.” It sets us a step above.

Mountain Valley Hospice & Palliative Care provides hospice services to terminally ill patients and their families in 17 counties from eight locations in North Carolina and Southern Virginia. Denise Watson has served as executive director since 1999, and has worked for MVHPC since 1994.

For more information or to download ACHC Distinction in Palliative Care Standards, visit cc.achc.org, email customerservice@achc.org or call 855-937-2242.

Maintaining Survey Readiness

ACHC Survey Readiness

As we embark into  2014, many of us set New Year’s Resolutions only to break our well-intentioned goals and ideals a few short weeks or months later as the daily hustle and bustle of life and work resumes. One New Year’s Resolution that should be established and kept is maintaining survey readiness. We know that we should always be “survey ready” but maintaining that on a daily basis becomes difficult as more pressing issues arise.

A few key points in maintaining survey readiness are:

  • Ensure you have the most current ACHC Standards for Accreditation and your policy and procedure manuals are consistent with ACHC Standards as well as any additional federal and/or local regulations.
  • Stay current with the monthly Did You Know publications sent by ACHC.
  • Audit medical and personnel records on a continuous basis to identify issues of non-compliance early and develop an internal Plan of Correction for any issues of non-compliance found.
  • Access ACHC’s Customer Central portal frequently for the latest information and resources to assist you in maintaining survey readiness.

ACHC has created tools to assist you with this endeavor. These tools coincide with key time frames; at 6, 12, and 24 months post-survey as well as 6 months prior to renewal.

For example, some annual requirements including program evaluation, staff education, and personnel evaluations are often overlooked or not completed on time. The tools ACHC has created provide you with checklists to help you to stay on track in between surveys. ACHC conducts surveys every three years, but as we know, random, unannounced surveys by any regulatory body could happen at any time and staying current is the key to a successful survey outcome.

Download the Continued Compliance documents by logging into your Customer Central Account and navigate to ‘After Accreditation’ -> ‘Continued Compliance’.

Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health

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Lisa MeadowsAbout the Author: Lisa Meadows

As Clinical Compliance Educator for Home Health, Hospice and Private Duty, Lisa brings over 20 years of medical social work experience to the classroom, including acute care hospitalization and home and hospice health care.  Previously an ACHC Hospice Surveyor, Lisa currently travels across the U.S. as a Presenter and an Educator, speaking on accreditation and other relevant health care topics.

Engagement is Everyone’s Job!

ACHC Survey the Expert with Barb

[iOS Users] [3:39]

In today’s Survey The Expert podcast Barb Sylvester, ACHC’s VP of Clinical Compliance, Regulatory, and Quality, will join us to discuss provider engagement in the accreditation process. Barb has over 30 years of nursing experience, including 19 years working in home health and hospice settings.

Episode Highlights:

  • Engagement is the responsibility of both the provider and the accrediting organization
  • How to best leverage strategic partnership between the provider and the accrediting organization and…
  • The best way to engage with the local community

Ready for accreditation? Contact ACHC at (855) 937-2242 to learn more.

Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health

 

Special Edition of Survey The Expert Podcast: Federal News Radio

ACHC_SurveyTheExpert_PodcastSeries_SpecialEdition150

[iOS Users]
[38:27]

José Domingos and Matt Hughes were recently interviewed on Federal News Radio. The discussion was about accreditation, as well as ACHC’s programs and services.

About Federal Tech Talk:
Federal Tech Talk looks at the world of high technology in the federal government. Host John Gilroy of the ARMATURE Corporation speaks the language of federal CISOs, CIOs and CTOs, and gets into the specifics for government IT systems integrators. John covers the latest government initiatives and the latest technology news for the federal IT manager and government contractor.

Home Health I Hospice I DMEPOS I Private Duty I Pharmacy I Sleep Behavioral Health

Getting Ready to Open Your Own Business? Make Sure You Answer Your Phone/Email/Social Media!

Starting a business is tough, especially in this uncertain economy. If you are ready to take the next step in opening a Home Health, Hospice, DMEPOS or any other business for that matter, your best strategy is to first know what you are up against.  Anyone who has taken a “Business 101” class knows that roughly half of new businesses close within one fiscal year. But here are a few interesting facts to help shape your business plan:

IT’S 50% EASIER TO SELL TO EXISTING CUSTOMERS.

  • 80% of your revenue will come from only 20% of your clients.
  • Keep all customers happy, but remember that your repeat customers are EXTREMELY valuable.

LEADS WANT A RESPONSE WITHIN 5 MINUTES OF INQUIRTY.

  • Less than 25% of small businesses respond within 5 minutes.
  • If the business calls/contacts back in less than 10 minutes, the potential client will be more responsive to discuss the service/product offering.
  • Remember there are many ways to open up conversations with clients: Phone/Email/Social Media.

DON’T GIVE UP!

  • Most small business reps give up after 2 attempts to reach a potential customer.
  • That’s why it is important to contact as soon as possible after the inquiry. The longer the business waits the more likely the potential client found a substitute.

Slowing sales and unforeseen economic/business conditions are the largest challenges businesses face – be it a start-up or an established business. Your best bet is to fully understand the needs of your market, join local associations, and connect in your community.  But as the data shows, your number one priority is to be accessible and responsive to potential and current clients.

*Check out the inforgraphic at Entrepreneur.com