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The Most-Cited Deficiencies of Sleep Labs During Accreditation Surveys

Updated: Jun 15, 2023

Nine deficiencies were found in over 10% of sleep centers during Accreditation Commission for Health Care surveys.

By Stefani Kim




Accreditation surveys can be likened to “open book tests on operating a high-quality sleep center,” according to Accreditation Commission for Health Care (ACHC) senior program director Tim Safley, MBA. But in sleep lab accreditation surveys conducted from June 1, 2021, to May 31, 2022, over 10% of surveyed centers failed to meet nine ACHC standards—worse than the prior year, when only three ACHC standards were lacking in 10% or more of sleep centers.


In its quarterly digital publication The Surveyor, ACHC details its most recent deficiency findings, including an overview of each standard’s intent, the evidence used to assess compliance, specific deficiency examples, and tips for avoiding these deficiencies at your sleep center. In addition, representatives from ACHC, as well as accreditation consultants not affiliated with ACHC, share insights with Sleep Review about potential reasons behind the citations as well as best practices for passing your own “open book test” with flying colors.


Top Sleep Lab Accreditation Deficiencies

The most-cited sleep lab accreditation deficiencies from mid-2021 to mid-2022, according to ACHC’s The Surveyor were:



An individual record is maintained for each client and contains current and accurate information. 50% of sleep labs cited. ACHC tip: Re-educate staff on the importance and expectation for timely, complete, comprehensive documentation of pre- and post-testing evaluations, equipment used, and other information.

Each sleep lab must develop a performance improvement program that includes measurement, analysis, and tracking of meaningful quality indicators and the actions taken when improvement opportunities are identified. 48% of sleep labs cited. ACHC tip: Set a reminder to complete semiannual performance improvement summaries.

The sleep facility writes a comprehensive annual performance improvement report. 48% of sleep labs cited. ACHC tip: The annual report uses data from the semiannual program summaries and augments with a description of corrective actions taken to make improvements on the findings of the data analysis.


Sleep lab clients/patients are provided with information regarding how to communicate a grievance/complaint with the organization, state agencies, and ACHC. 33% of sleep labs cited. ACHC tip: Consider a “patient instruction checklist” identifying all items provided directly to the patient and maintain a copy in each patient file.

Each performance improvement activity/study describes the data to be collected, the collection method and frequency (including the responsible party), a benchmark or range for acceptable performance, the corrective action when an improvement opportunity is identified, and the reporting flow. 25% of sleep labs cited. ACHC tip: This standard addresses detailed documentation of each performance improvement activity/study. For each metric collected, a goal or benchmark should be identified. When the benchmark is not achieved and a performance improvement activity is initiated, corrective action should be identified, followed by remeasurement. This cycle may need to be repeated several times to achieve and maintain the benchmark. Documentation and communication are essential to sustain the improvement.

The organization maintains written contracts/agreements that define the scope and expectations for services provided by outside personnel. 23% of sleep labs cited. ACHC tip: Collect a copy of professional liability coverage certificates at the initiation of an agreement and calendar expiration dates to prompt for evidence of coverage renewal, especially if the expiration of the liability coverage will occur earlier than the end date for the contract.





Client/patient records include documentation of communication regarding the client’s/patient’s financial responsibility for services. 21% of sleep labs cited. ACHC tip: Conduct periodic chart/file audits for completeness.

For personnel providing direct client/patient care and those with access to client/patient records, a background check is required with evidence maintained in individual personnel files. 21% of sleep labs cited. ACHC tip: The sleep lab is not prohibited from hiring an individual who has been convicted of a crime, but policies and procedures must include documentation of any special considerations, restrictions, and additional supervision required.


The sleep lab’s medical director or certified sleep physician provides monthly education for personnel. 21% of sleep labs cited. ACHC tip: Establish monthly in-service training. Topics should include at least an equipment review, facility policies and procedures, and clinical protocols.


Why Did Sleep Lab Survey Deficiencies Increase?

ACHC attributes the sleep lab deficiency increase in part to an accelerated return to normalcy after several years of COVID-19 pandemic disruption. In other words, as increasing numbers of sleep centers had to ramp up quickly, more standards fell through the cracks. Another reason is simply increased survey volume as more sleep labs sought accreditation.





According to Andrea Clark, DBA, MSW, RPSGT, president of sleep consulting business Signature Sleep Services LLC, smaller facilities may have found themselves constrained by a competing list of priorities other than accreditation.


“The accreditation process is complex and time-consuming,” Clark says. “Most technologists lack experience developing policies and procedures and their roles in performance improvement. Physicians may also be inexperienced with the administrative side of a sleep medicine practice. Smaller facilities generally have one or two technologists that perform studies at night, and scoring may be outsourced. Therefore, with limited staffing during the day, who will be responsible for compliance with the various entities’ accreditation standards?”


Sleep medicine has shifted from large, hospital-based labs that have human resource and risk management departments to help guide the accreditation process to smaller, out-of-center testing facilities, she adds. As home sleep testing increased, “larger facilities with multiple locations were no longer sustainable. These facilities had the financial resources to provide technical supervision, oversight, and leadership that developed, implemented, and monitored accreditation standards”—all of which can be lacking in small sleep labs.


Additional challenges relate to extended pandemic-related closures. Like many healthcare providers who pivoted to telehealth during pandemic lockdowns, sleep labs experimented with home-based tests as an alternative or supplement to in-person testing, according to Safley.


“Many labs have made adjustments in their business model,” Safley says. “One example is the increased use of home sleep testing (HST) as a tool for diagnosis or confirmation that an in-lab study is needed. We have seen rapid technology advances to enhance the capabilities of HST and give the prescriber better data. Any advance in the accuracy in HST is a good thing, and advancement in virtual monitoring overall has played a key role in the world of sleep medicine.”


Accreditation organizations also tailored their sleep lab accreditation surveys to account for COVID-19 safety precautions.


“Concurrently with the pandemic, ACHC was able to initiate a virtual survey process,” Safely says. “Strict guidelines define when a sleep lab can be surveyed virtually, but this type of survey that limits in-person contact has been beneficial for our eligible customers. As COVID drove a focus on how to be more efficient in our evaluation of our sleep facilities, it has also provided opportunities for more customer education on infection prevention strategies.”


Future of Sleep Lab Accreditation

Troy Lair, a principal at Elite Accreditation Consultants, says the normalization of home-based assessments could potentially overhaul the accreditation process. “I see CMS (Centers for Medicare & Medicaid Services) and the private accrediting bodies moving towards a more simple-to-manage accreditation process and compliance expectations becoming more realistic and more impactful as they are revised,” he says.


Clark says accreditation organizations could improve compliance rates by providing educational materials that are specifically focused on the development of policies and procedures for meeting standards within sleep labs. “For example, education programs on what elements the accreditation organization expects in a performance improvement plan and what processes the lab should monitor,” she says. “Many of the non-hospital-based sleep centers I have worked with needed to learn what performance improvement is, how to write a plan, what an indicator is, how to monitor it, and if the threshold needs to be met, what to do to correct it.”


ACHC’s Safley says, “Generally, our approach is about helping sleep facilities become better while meeting requirements to be paid for the testing that is performed. Deficiencies can be avoided by taking full advantage of educational resources.” At ACHC, these include a team of RPSGTs/RRTs who have worked in and managed sleep facilities, free webinar workshops, and a “Guide to Success” workbook.


“Sleep medicine is still evolving, from testing all the way to the diagnosis and treatment. The two things we see are the overall growth in the technology, that is, the sophistication of sleep equipment and changes in the requirements for a sleep test to be covered by a payor. This ever-changing environment is why ACHC stays in touch with both sides of the equation—our accredited organizations and the payors—to fully support the needs of all stakeholders,” Safely says. “There will always be deficiencies noted because there is always opportunity for improvement. My hope is that with the resources and knowledge we provide, the frequency with which any individual standard appears will continue to diminish.”


Reference

Accreditation Commission for Health Care. The Surveyor. 2022(2):Quality Review Edition (Sleep). Available at www.achc.org/publications.



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