Pg. 05 achc responds to covid-19 crisis

[Pages:28]SUMMER 2020

achc accredits first assisted living community

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ceo report pg. 05

achc responds to covid-19 crisis

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achc welcomes new leaders

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a neewdulcoaotkioant pg. 27

THE SURVEYOR I SUMMER 2020

BOARD OF COMMISSIONERS

Denise Leard, Esq I Chairperson

ATTORNEY, BROWN & FORTUNATO

Leonard S. Holman, Jr., RPh I Vice Chair

SEASONED HEALTH CARE ANCILLARY SERVICES EXECUTIVE AND CONSULTANT

Gregory Bentley, Esq I Secretary

PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM

William R. Letendre, Sr., MS, MBA I Treasurer

VICE PRESIDENT OF PHARMACY MANAGEMENT

John Barrett

SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING

Jos? Domingos

PRESIDENT AND CEO, ACCREDITATION COMMISSION FOR HEALTH CARE

Richard A. Feifer, MD, MPH, FACP

CHIEF MEDICAL OFFICER, GENESIS HEALTHCARE

Barbara Stover Gingerich, RN, MS, FACHE(R)

PRESIDENT, ADVANTAGE CONSULTANTS, INC.

Marshelle Thobaben, RN, MS, PHN, APNP, FNP

PROFESSOR, HUMBOLDT STATE UNIVERSITY

Tom Tucker

VICE PRESIDENT OF SALES AND MARKETING, ATTENTUS MEDICAL SALES, INC.

LEADERSHIP TEAM

Jos? Domingos I President & CEO Matt Hughes I Director, Business Development Denise Hobson I Program Director Jon Pritchett I Program Director Gina Eastridge Reynolds I Vice President, Finance & Operations Tim Safley I Program Director Barb Sylvester I Director, Regulatory Affairs & Quality

Chipping in for Charity

May 17, 2021 Register now at

2 I 855-937-2242 I

your donations help us strengthen our community

Net proceeds benefit these local organizations serving counties throughout Central North Carolina.

table of contents 04 alicvhincgacccormemduitnsitfyirst assisted

Mitchell House Assited Living & Memory Care

05 corner view CEO Report

06 covid-19 crisis (cover story) ACHC's multipronged response to the pandemic

08 program updates Hospice, Home Health, Private Duty, DMEPOS, Pharmacy, PCAB & Sleep 14 achc welcomes new leaders Promotions and new hires

1 8 cms recognition Home Infusion Therapy & Hospice programs

20 partnerships Partnering today for growth tomorrow

22 orefnf-aslitdeiarleyvsiieswpsrofovriders Surveys for temporary accreditation

23 provider spotlight Franciscan Durable Medical Equipment

24 tailored educational resources ACHCU features a variety of workshop options

25 expansion update ACHC International

26 evidence requirement change ACHC eases survey evidence requirement

27 healthtrainu A new look at education

THE SURVEYOR I SUMMER 2020

06 18 22

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afliicrvhsinctgaaccscosrmisemtdeuitdnsity

ACHC reached another milestone with the recent accreditation of its first assisted living community, Mitchell House Assisted Living & Memory Care in Spruce Pine, N.C. ACHC understands the value placed on assisted living communities not only for residents, but also for their families. Our focus on both the quality of care and the quality of living is what helps ACHC Accreditation stand out from the rest. Because of this commitment to quality, ACHC will officially launch its Assisted Living program with accreditation for Assisted Living Communities later this year.

To be recognized by ACHC is a huge honor that we will be proud of for years to come."

-- Tennille Garofola Mitchell House Executive Director

"In achieving accreditation, Mitchell House has demonstrated its commitment to strengthen its foundation and enhance organizational performance," said Denise Hobson, ACHC

Program Director. "Accreditation standards set quality benchmarks that promote improvement throughout all aspects of the assisted living community while directly impacting the residents' quality of life."

Mitchell House, an Affinity Living Group community, combines the comforts of home with the health and personal care needed for residents to live fully and comfortably. Staff is dedicated to providing a safe, warm, engaging environment for all residents.

"To be recognized by ACHC is a huge honor that we will be proud of for years to come," said Tennille Garofola, Mitchell House Executive Director. "We respect the work they have done and the high standards of their accreditation process, so this recognition is something we hold high.

"In the assisted living industry, we are entrusted to care for a vulnerable population," Garofola said. "There can never be too much oversight when it comes to making sure our beloved residents are cared for to the highest degree. I am beyond proud of our team here at Mitchell House for always going above and beyond in caring for our residents. This accreditation is a testament to their hard work and dedication."

Learn more about Assisted Living and other accreditation programs from ACHC. Visit , call (855) 937-2242, or email customerservice@ for more information.

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corner view

Jos? Domingos, PRESIDENT & CEO

The COVID-19 pandemic has touched all of us and as

as an extension of your organization. Our friendly, supportive

healthcare providers, you have been there every day, making Account Advisors and clinical experts are available to give you

sure patients get the best care despite overwhelming

the latest information on accreditation and compliance issues,

challenges.

and will work with you to meet your individual needs. We also

Accreditation Commission for Health Care (ACHC) understands how difficult this time has been for you and is

regularly provide updates on our website and through emails and social posts.

grateful for your compassionate efforts. Please know that

When it comes to surveys, ACHC is constantly monitoring the

your commitment to providing

situation and conducting appropriate

critical community services has not

surveys while taking the proper

been overlooked and is very much

You can continue to

precautions. We are also offering virtual

appreciated by everyone at ACHC. We will do what we can to support you in those efforts.

depend on ACHC to assist you during these

non-deemed initial and renewal surveys and temporary accreditation for select programs.

While we have also faced our own

difficult times.

Our interest is to meet your specific

challenges, it's been a balancing

needs while taking the proper

act, and ACHC remains available

precautions to keep both your staff

to support your needs. By the time this is published, I suspect

and our staff safe. You can continue to depend on ACHC to

that we will still be dealing with uncertain times. We will remain assist you during these difficult times. We will get through this

flexible by balancing the need for surveys with the safety of

together by doing our best to keep those we serve safe.

your employees and patients and our staff. We are committed to If at any point you have concerns, please reach out. As your

taking care of you and the specific needs of your organization.

trusted partner, there isn't any situation we can't manage

Many of you have reached out to us with questions and

together. Best of luck on a prosperous and healthy remainder

concerns, and we appreciate you doing so. We're listening and of 2020 and thank you for choosing ACHC as your accreditor

are here to help. I have always suggested that you use ACHC of choice.

Jos? Domingos President & CEO

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atochccorveids-p1o9ncdrsisis

The past few months have been a challenging time for healthcare providers. Many of you have operated at peak levels to meet increased demands during the COVID-19 pandemic while also taking additional steps to protect staff and patients from the spread of infectious disease.

ACHC knows it hasn't been easy, and appreciates your dedication to providing critical community services. While the long-term impact of the virus is uncertain, we are working with each of you to learn more about your circumstances so we can best meet your specific needs.

We are closely monitoring local, state, and federal healthcare websites and communicating regularly with the Centers for Medicare & Medicaid Services (CMS). This enables us to keep you informed on the most up-todate government recommendations. In accordance with these guidelines, we adjusted certain policies and procedures, easing your administrative burdens during the COVID-19 public health emergency.

You can rely on ACHC for support throughout the crisis and beyond. As always, we are committed to helping you maintain a safe environment and best serve your communities, employees, and patients. To help you respond more effectively, ACHC is continually finding more ways to assist you during the coronavirus pandemic.

provider resources

Information on the virus is ever-changing, and ACHC responds quickly to updates, sending you emails and social posts to keep you informed of the latest industry and program guidelines.

We also created a special COVID-19 provider webpage to give you convenient access to the most current resources for providers. The webpage features our Frequently Asked Questions, which include responses to common questions about COVID-19. We regularly update our FAQs to remain

here to help

As we navigate changes in these difficult times, ACHC remains flexible and focused on meeting your individual needs. We're listening and are here to help.

From answering your accreditation questions to keeping you up to date on the impact of COVID-19, ACHC is dedicated to delivering the highest quality customer service. Our Account Advisors and clinical experts are available to give you the most current information on accreditation and compliance guidelines while working with you to address your needs.

Thank you for reaching out to us with your questions and concerns about the COVID-19 situation. Please continue to contact us at ProviderSupport@ for assistance.

Access COVID-19 resources at coronavirus.

accurate and current, and continue to include program-specific guidelines from CMS as it broadens flexibilities and eases requirements during the COVID-19 public health emergency.

The webpage also includes a continuous news feed from the Centers for Disease Control and Prevention (CDC) and links to other industry-related articles, such as safety precautions, telehealth resources, and coping with the COVID-19 situation.

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Additionally, ACHCU is partnering with industry experts for

surveys

special monthly webinars on the most current COVID-19 information and guidance for providers. ACHCU still continues

ACHC considers conducting surveys part of our responsibility to provide free monthly webinars on industry updates across

to support community-based providers, ensuring they are

all programs. Check out the webinars we have coming up and

fully operational and prepared to participate as a provider

access all previous webinars on demand at . For

in the healthcare continuum. To support providers, ACHC is more information on ACHCU services, please visit ,

currently conducting some initial and

call (919) 228-6559, or email

renewal on-site surveys, depending

customerservice@.

on the program and the number of positive COVID-19 cases in the county where the organization is located.

ACHC also is offering virtual nondeemed initial and renewal surveys and temporary accreditation for select programs, giving providers more ways to demonstrate compliance with quality guidelines

ACHC supports the use of face masks or other facial coverings in all public settings as an important step to slow the spread of COVID-19."

face masks

ACHC published a position statement promoting the use of facial coverings in public as a precaution against the spread of COVID-19:

"ACHC supports the use of

and essential infection prevention and control measures.

-- ACHC Position Statement

face masks or other facial coverings in all public settings

as an important step to slow the

spread of COVID-19."

surveyor screening

The ACHC statement was released in response to recent

ACHC Surveyors conducting on-site surveys are

studies showing that some people infected with coronavirus

following CDC measures to prevent the spread of infectious

who lack symptoms and those who eventually develop

disease. As a further safety precaution, they also are self-

symptoms can transmit COVID-19 to others before showing

monitoring their health and providing a form certifying that

symptoms. Also, the virus can spread between people -- by

on the morning of each day of an on-site survey they are

speaking, coughing, or sneezing -- even if those people are

symptom-free and following CDC measures. Organizations

not exhibiting symptoms.

being surveyed are required to provide personal protective

equipment (PPE) for the Surveyor.

virtual educational resources

ACHCU, the educational division of ACHC, helps providers stay up to date on new regulations, industry hot topics, and accreditation updates. ACHCU is offering virtual workshops that bring the full workshop training experience to you in an online, on-demand format. ACHCU also is hosting live, online workshops during the COVID-19 crisis. Continuing education credits are still available for online workshops.

in this together

During this time of crisis, we are genuinely grateful for the courageous efforts of all healthcare professionals, and are doing our part to ensure providers are fully operational and prepared to respond to increased demands.

We're all in this together and we'll get through this together.

ACHC values the health and safety of providers, employees, and patients, and appreciates your continued trust in us. For more information on programs and services, please visit , call (855) 937-2242, or email customerservice@.

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program updates

The Centers for Medicare & Medicaid Services (CMS) recently passed the Omnibus Burden Reduction (Conditions of Participation) Final Rule, which aims to remove "unnecessary, obsolete, or excessively burdensome" healthcare regulations and increase focus on patient safety and care. The Final Rule went into effect November 29, 2019.

One change for hospice agencies is that they now can defer hospice aide training and competencies to state licensure requirements. If there are no state requirements, hospices will still be required to ensure that their hospice aides meet federal standards for hospice aide training.

Emergency preparedness requirements also were revised. The annual review and update to the all-hazards risk assessment, policies and procedures, communication plan, and training now are required to be reviewed and updated at least every two years. The expectation is that if a significant change is made to policies and procedures, then training should be performed in a timely manner to ensure staff is aware of the change.

The testing of the plan changed from two drills annually to two drills every two years. In the year opposite the fullscale or functional exercise, the agency should complete a second full-scale exercise that is either community-based; an individual, facility-based functional exercise; a mock disaster drill; a tabletop exercise; or a workshop that includes a group discussion led by a facilitator uses a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

Functional exercises focus on exercising plans, policies, procedures, and staff members involved in management,

Please call us at (855) 937-2242 or email customerservice@ to learn more about ACHC programs and services

direction, command, and control functions. Compared with a full-scale exercise, a functional exercise involves fewer participants, and the movements of personnel and equipment is simulated.

A mock disaster drill focuses on practicing how to save lives in a real-time situation for any kind of danger/calamity that occurs with no advance or very little time to evacuate from the premises.

The Final Rule aims to remove "unnecessary, obsolete, or excessively burdensome" healthcare regulations and increase focus on patient safety and care.

CMS also removed the requirements to have a person on the hospice staff who has specialty knowledge of hospice medications, even though the expectation is that hospice providers should have individuals knowledgeable in hospice medications.

The requirement for hospices to explicitly coordinate with Skilled Nursing Facility/Nursing Facility (SNF/NF) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) staff for orientation of facility staff was also revised to lessen the burden. However, the expectation remains that the hospice and SNF/NF and ICF/IID staff work together to ensure facility staff are oriented to hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, and symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record-keeping requirements.

-- Lisa Meadows, ACHC Clinical Compliance Educator

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