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Top 10 Overlooked Standards

May 2020


Success Can Be Yours!

ABC wants your onsite survey experience to be positive and successful. Our goal is to provide you with all of the resources and information you need to be completely prepared for your survey.

Keys to Success

      Thorough knowledge and implementation of the Standards

       Of course nothing can replace a thorough knowledge of the Standards! This is your starting             point when preparing for accreditation.

      Utilizing Resources

       Take advantage of the many resources available on our website such as the Patient Care                 Facility Accreditation Guide with all of the Standards as well as tips for compliance; the                   Custom Standards Tool to generate a list of specific Standards that pertain to your business;                                and the Compliance Kit with a handy calendar and 20+ forms, templates and checklists to                                    help you stay compliant year-round.


      The Top Ten

       ABC has reviewed the results of many onsite surveys and created a list of the items or areas           that frequently result in a partial or non-compliant score during the survey. A partial or                       non-compliant score in any area can mean the difference between passing and failing your                                  onsite survey and in many cases may result in a request to submit a Corrective Action Plan                                    (CAP).

The following 10 items are the ones most frequently overlooked:

   Conduct and evaluate your annual emergency evacuation drill and be sure to document your results.       (FS.3.2.1, FS.3.2.2)

   Perform an annual review of your performance management program. (PM.10)


   Continuously audit and monitor your claims and billing compliance program and don’t forget to                 document your findings and any corrective actions that you have taken. (CB.4.1)

   Before a device is delivered to the patient, make sure that it meets all manufacturer guidelines and           confirm that the item reflects the patient’s prescription. (PS.9.2)

   All staff that is responsible for patient care have included documentation of the patient’s progress in       meeting specific goals and expected outcomes for the use of the item in the patient’s chart. (PC.4)

   Every patient is provided with instructions for the care and use of their device and this activity is               documented within the patient chart. (PC.6.1)

   Patient charts are consistent and complete. (Including all the elements described in PR.6.1)                                

   You seek input from your employees, patients and referral sources when assessing the quality of your     operations and services. (PM.1.1)

   Results of your patient satisfaction surveys are documented and evaluated as part of your                         performance management program. (PM.2.1)

   When an opportunity to improve the quality of care is identified, action is taken. Make sure you                 monitor these actions on an ongoing basis to assess their effectiveness in improving your quality of       care. (PM.9)

All of these items and more can be found on the Onsite Survey Checklist—a great tool to use to track your progress towards compliance! Download the Checklist on the ABC website.

Ask Questions

That’s what we’re here for. ABC’s knowledgeable staff is available to answer your questions and help guide you through the accreditation process. Please don’t hesitate to give us a call at 703-836-7114 or email us at accreditation@abcop.org.