Accreditation Medicare Survey Form
Office / Administrative Requirements
| COMPLETED | Item | Comments |
|---|---|---|
| Office handicap access | Must make reasonable accommodations | |
| Compliance with state and local zoning requirements | ||
| Posted operating hours, agency phone number, and emergency after-hours contact | Outside entrance | |
| Smoke-free facility signage | Downloadable from online sources | |
| Framed agency license | Visible in the office | |
| Privacy Notice posted | In agency materials, framing not required | |
| CLIA certificate posted | Framed and visible | |
| Mission statement posted | Framed and visible | |
| Patient’s Bill of Rights posted | In policy manual, can be printed for office display | |
| "OIG Report Fraud" poster | Found in agency materials | |
| Federal OSHA, child labor laws, employment opportunity law, hazard communications, and worker’s compensation law posted | Available at All-in-One Posters | |
| Worker’s compensation insurance | Not required in Texas | |
| Emergency exits map | Framed and posted | |
| Exit signs | Illuminated or glow in the dark | |
| Comprehensive Emergency Management Plan (CEMP) | Includes Business Contingency Plan, Agency Risk Analysis, and Communication Tree | |
| Alternate operating location in emergency | Documented | |
| Agreement with staffing agency for COVID pandemic | Contract with local healthcare staffing agencies | |
| Annual fire drill | Conducted and documented | |
| Fire inspection | Current and on file | |
| Fire extinguisher | Annual inspection and monthly logs | |
| Agency supplies | Limited initial supplies | |
| After-hours call forwarding or answering system | RN on call required | |
| Monthly RN on-call schedule | Needed after first patient admission | |
| Waste disposal plan (mailable or contracted) | Cost-effective options available at Sharps, Inc. | |
| Waste disposal container & sharps signage | Controlled area, labeled | |
| General & professional liability insurance | Contact Holden Haws (305) 452-0587 | |
| Surety bond (if required by state) | Gallagher Affinity Insurance Services, Inc. (888)278-7389 | |
| Secured patient records and personnel files | Locked file/closet with double lock (file and door) | |
| Personal Protective Equipment (PPE) Kits | Minimum of two kits available | |
| Safety Data Sheets (SDS) | Located on shared files | |
| OASIS & Medication Profile forms | Hard copies or software accessible | |
| Organizational Chart | Updated with names and titles | |
| Communication Tree / Plan | Distributed to all staff and included in emergency plan | |
| Current contracts | Reviewed annually; addendums for therapy contracts | |
| Business Associate Agreements (BAA) | Signed as appropriate | |
| Operating Budget, Capital Expenditure Budget, and Strategic Plan | Completed and up-to-date | |
| Articles of Formation | Available | |
| By-laws or Operating Agreement | Available for corporation or LLC | |
| Administrator & Governing Body reviewed policies | Sign off initially and yearly | |
| Emergency Disaster Plan / Policies | Completed and reviewed | |
| Employee Handbook & Orientation Manual | Tailored to agency specifics | |
| Staff Photo IDs | Issued, can use services like Best Name Badges | |
| Admission Packet for Surveyor | Must contain agency contacts, bill of rights, privacy notice, complaint process, safety info, and discharge policy |
Personnel Records
All personnel records should be organized as follows:
- Main File (6 Sections): Use dividers for easy reference.
- Confidential File (Section 7): Labeled confidential and includes health info and criminal background checks.
Print and use the Personnel File Audit Tool to ensure compliance.
| Item | Comments |
|---|---|
| Orientation | All staff must complete orientation prior to seeing patients. |
| Clinical Staff Competency | Competency evaluations required before patient care. |
| Background Checks | Follow state-specific criminal background policies; OIG and National Sex Offender checks for all employees. |
| Conflict of Interest Form | Signed by all employees. |
| TB Testing for Clinical Staff | Follow TB Policy for initial and annual testing as per state regulations. |
| Employee Roster | Includes name, hire date, position, and direct/contract status. |
Additional Requirements for TB Testing
Baseline Testing (Two-Step Test):
- First TST: Administer, review, and document results.
- Second TST: Administer within 1–3 weeks if first test is negative.
Ongoing Testing:
- Per state regulations or risk assessment outcomes.
Ensure compliance with TB documentation and clearance for clinical staff prior to care.
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