It’s a new year! Have you scheduled your annual agency requirements?

Yep it’s a brand New Year! Thought I’d post a reminder about your Medicare/CHAP requirements

1. Obviously, you’ve made arrangements for your Medicare Cost report

2. Have you made arrangements for an “external financial review”? CHAP standards CIII.3 requires that an accountant review the books of the agency and document that the agency followed Generally Accepted Accounting Principles” CHAP requires this annually. Of note “external” means not an employee or owner.

3. Very important: Annual agency evaluation (that means EVERY year) and not having it done every year could be a condition level (the kind that requires you to clear it in 90 days with another visit from CHAP). In addition to doing it, it has to be approved by the PAC and the GB and documented in the meeting minutes.

The annual agency evaluation is a report and many surveyors are not accepting the checklist format that has become popular over the years.

4. The governing body and leadership must sign statements disclosing conflicts of interest. These are usually filed I the annual governing body meeting

5. Be sure to document in those governing body and meeting minutes all the things that are required of those committees: Review of policies and procedures, mission statement, strategic plan, etc, etc, etc.

6. Annual requirements for personnel include

1. a clinical competency performed by same discipline (RN for RH, LPN, HHA, PT for PT, OT for OT, ST for ST, et)

a) a joint visit with supervisor (doesn’t have to be like discipline)

b) a performance evaluation

c) 4 annual in-services (Infection Control, TB, Bloodborne Pathogens, and Medical Device Act)

d) Some states require TB tests (instead of screening questionnaire) this is also governed by your policy, so check that out.

Recertification (your 3 year survey) has way more moving parts and as such more opportunities for Condition level Medicare deficiencies. That’s the ones you’ll have to clear within 90 days in order to keep your Medicare number.

The most common Condition level deficiencies involve aide services, professional advisory committee membership and meeting requirements, annual agency evaluation, governing body responsibilities.


Happy 2015!!

Obviously, if you need any help with your annual agency evaluation, strategic plan, meeting minutes etc. I am happy to schedule a day or two at your agency to help you knock that out.




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