Keeping track of your facility’s standards compliance is important, especially for those standards that must be completed every year. In fact, our surveyors indicate that compliance with annual standards is an area where facilities tend to fall short. If you delay these annual tasks until the last minute, it may affect the quality of your review process and or even cause them to get overlooked and missed.

Compliance with these annual standards can greatly improve the outcome of your onsite survey and reduce the chance of needing to do a Corrective Action Plan (CAP). Take a few minutes to review the list of annual standards and tips for making compliance with these standards even easier.

AD.3.1.1 – Review your written policies and procedures and document that review. 

AD.5.1 – Review the Office of Inspector General (OIG) List to ensure that no employees, contractors and new hires are on the list.

HR.2 – Document verification of staff certifications and licenses. 

HR.7 – Conduct employee performance reviews. 

PC.8 – Assess risk from emergency and disaster and ensure a contingency plan addresses the identified risks. 

PC.9.1 – Conduct and document effectiveness of emergency disaster drills. 

PM.1.1 – Document how you seek input from employees, patients and referral sources. 

PM.2.1 – Review patient satisfaction surveys and document how you use the results. 

PM.10 – Review your written performance management program and document any changes that were made. 

FS.1.1 – Review your written safety management program and document your annual safety inspections and any corrective actions taken. 

FS.3 – Conduct and document safety management for all staff. 

FS.3.2.1 – Conduct an emergency evacuation drill. 

FS.3.2.2 – Document the effectiveness of your evacuation drill. 

CB.4.1 – Write and evaluate the results of file auditing and monitoring. 

Compliance Tips

TIP 1: We recommend creating an annual compliance standards schedule and setting reminders to ensure these tasks aren’t left until the last minute.

TIP 2: If you find yourself overwhelmed during the hustle and bustle of the holiday season along with taking care of year-end financials, consider looking back at your facility’s calendar for the year to determine when your administrative workload was lower and try scheduling annual compliance activities during those slower times.  

TIP 3: Refer to our Annual Facility Review Checklist in the online Resource Pack for additional guidance and utilize the Resource Pack items created specifically to help with many of the annual compliance standards.

Staying on top of your annual compliance standards doesn’t have to be daunting. If you make a plan to spread compliance tasks out during the year and take advantage of the many resources available, you’ll be setting yourself up for successful compliance year after year.