Surveyor Notes — Annual Compliance Documentation: The Long Game

By Joan M. Zinter, CPO, Surveyor

It is important to remember that your upcoming facility accreditation survey is based on a three-year span of compliance activities. When we refer to annual compliance, we aren’t merely speaking about your compliance for the year in which your survey is conducted but all three years that have passed since your previous survey. This can seem like a lot to keep track of, but staying organized and on top of your documentation each year will make the process much easier. In fact, it is your annual compliance documentation, or lack thereof, that is the basis on which we determine whether your business will be awarded a 3-year accreditation (with or without a corrective action plan). Your surveyor will want to see three years’ worth of annual documentation for things like fire drills, safety inspections and performance management reports.

Compliance activities prior to the current three-year span have no bearing on your current survey score. These older documents may demonstrate a history of compliance, but again, they do not reflect activities related to your present survey. In fact, you aren’t even required to retain older accreditation-related documents to maintain your facility accreditation.

When an ABC surveyor arrives at your facility and requests to see your accreditation compliance documents, what thoughts go through your mind? Are you thinking “No problem! They’re right here.” Or, are you panicking inside and trying to quickly map out the many places your documentation might be — in a binder somewhere in the front office, maybe some documents are in the lab and perhaps your billing staff has the rest.

If finding your compliance documents is like a treasure hunt, it's time to think about finding a centralized location to store and organize them. Quick and efficient retrieval of these documents gives you a head start for a successful survey experience. A well-organized compliance binder or electronic spreadsheet is a good place to start. When your staff can easily find the information, it not only makes completing the required tasks quicker but also helps make documenting it each year that much easier.

Below is a list of annual documents required for your survey. Be sure you’re familiar with these requirements and if you haven’t already…start getting organized!


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