DMEPOS's Top Deficiencies of 2025

We break down the top 10 DME survey deficiencies for 2025 and why annual CMS oversight raises the bar for safety, compliance, and documentation. Practical steps show how to turn policies into proof, strengthen QuAPI, and align multi‑site operations.

• CMS’s increased oversight and annual DME surveys
• the role of survey readiness and mock surveys
• building an effective compliance program using OIG’s seven elements
• quality assurance and performance improvement as a monitoring engine
• safety program gaps including tank storage, transport, cleaning and PPE
• TB screening requirements and aligning policy with state and CDC
• documentation errors that mask compliant practice
• training versus competency and observed skill assessment
• leadership accountability and consistency across multiple locations

After you listen to this podcast, click on some of the links to our resources: our top 10 DME survey deficiency list, which includes our three-year comparison.

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Transcript

SPEAKER_02 0:16

Greetings. This is Jennifer Kennedy, the lead for compliance and quality at CHAP, and welcome to CHAPCAST. So if you uh were with us as a home health or a hospice provider, we uh regaled you with the top 10 survey deficiencies uh for 2025 for uh both of those uh spaces. And now today we are going to talk about the top 10 deficiencies for DME in uh 2025. So I am so pleased to be joined by um my two colleagues, uh Kim and Shannon. And um Shannon, uh I I I know you've been with us one or two times before with Kim Ski and myself. Why don't you go ahead and introduce yourself and say what you do here at CHAP?

SPEAKER_01 1:10

Sure. Um I am a senior director of accreditation with CHAPTER. I've been with the organization for about five years, and one of my primary responsibilities is to um oversee the demi pose organizations for which we accredited.

SPEAKER_02 1:23

Great. And Shannon, you are our CHAP guru for all things DME. So we're gonna, you know, no pressure on you during this podcast today.

SPEAKER_00 1:34

I second that. Yeah, I don't like that word.

SPEAKER_02 1:38

And of course, uh we've got Kim Skian. Uh she is the VP for accreditation, good friend, colleague. I don't know, what else are we? Sisters from another mother, maybe? I don't know.

SPEAKER_00 1:50

Kind of feels that way sometimes. Uh and we come and we commiserate together on um any of these regulatory changes and challenges. So, but we're, you know, in it together. Absolutely.

SPEAKER_02 2:03

So um we're gonna go ahead and and get going with the with talking about the top 10 um DME deficiencies, but I just wanted to uh put out there that with such a you know with such big changes in the DME space and such a focus on um DME from CMS, I think it's like more important than ever that uh suppliers and providers take heed to what the top 10 deficiencies are. And I'll throw it out to Kim and Shannon for their thoughts on that.

CMS Oversight And Annual Surveys

Why Survey Readiness Matters Now

SPEAKER_00 2:39

Sure. Thanks, Jennifer. I'll start um and then and then pass off to to Shannon for her expertise. But just to sort of lay the groundwork, DME has been um increasingly in the spotlight with CMS for quite some time, both from a potential fraud and billing standpoint, but also from a uh regulatory concerns about uh health and safety. So we've seen over the past year or so, just as a demi post accredit deemed accrediting organization, um, where CMS has increased some oversight and some, you know, some processes and practices that would be more visible, if you will, to an AO than to the providers. Um, and this doesn't count any billing audits, this is about survey. Um, but with the fit the fiscal year 2026 home health final rule, uh, there were significant changes to DM Demi Post, not just the um related to the um, you know, uh the competitive bidding and some of the other um the other areas that that Shannon is fully uh well-versed in, but most importantly, certainly impacting us, were the changes to the AO oversight or accreditating accreditation organization oversight and providers. So notably increasing surveys from every three years to every year. So annually every sir every year, or annually, every uh DME provider needs to be surveyed. And there's a lot of discussion and development around the sampling methodology, um, you know, in terms of CMS wanting to make sure that um that AOs are surveying not just one if if an organization has multiple entities, but you know, one or the same organizations over time as they used to look at heat zones, for example, really making sure that there's a represent representative sample of all of the um providers. So it's going to be a greater chance that each location will be surveyed at least, you know, uh at least once, you know, uh during the uh a regular cycle. And but if you're a single provider, it's annual uh surveys. And what that means is if you haven't paid attention to survey readiness and these top-dent deficiencies, then you really need to start to put together a survey readiness program. You know me, every service line I ever speak about, I talk about survey preparedness and conducting mock surveys, but also being aware of the CMS demi-post quality standards, the CHAP standards if you are CHAP accredited, and what those key areas are that you can, to the best of your ability, control. Because the other piece that's important here is it's it's not well defined with demi-posts, um, where home health and hospice you have standard level deficiencies, condition level deficiencies, and um then immediate jeopardy and termination. With demiposts, they have um that the it's really up to the or uh the AO. And but the one thing that CMS is looking for is if the AO determines that a plan of correction is recommended versus denial of accreditation, the AO must include in their report to CMS the rationale for the POC versus denial. So there's a lot more scrutiny in addition to validation visits. So a lot of eyes on DME from the regulatory standpoint, which is why what Shannon's gonna talk about with the top 10 deficiencies is so important.

SPEAKER_01 6:38

Yes, correct. Go ahead, take it away. Well, I mean, site visit readiness is um you know a must these days, right? We've we've always preached site visit readiness. However, now with the annual accreditation cycle, it is more important than ever. And each organization should really focus on their quality assurance and performance improvement programs to ensure you know that they are monitoring their own internal processes and identifying opportunities for improvement. And I think that's really going to be key to any organization's um you know self-readiness.

The Role Of Compliance Programs

SPEAKER_02 7:17

So thank you so much for that great setup. Um when we look at that top 10 list for 2025, Shannon, is there anything that pops out to you as a surprise or um or anything that doesn't surprise you for that, for that matter?

SPEAKER_01 7:35

No, I think in looking at it, um, it's pretty common across the board, especially even when Jennifer you did a great job putting together that three-year um history perspective. And really all it all it does is it's really the same top 10. They just move around, right? A little bit from year to year, depending on the organization's focus. Um, but really what this comes down to is implementation of organization policy and procedure. And I believe just from experience and operations, is you know, it's I I won't say easy, but but it's fairly, I believe, easy to establish policy and procedure. It's implementing it because right, you have humans, you have human error, um, you have stressful days, you have all types of elements that will affect implementation. And and so again, quality assurance, we call it coffee, quality assurance, performance improvement. You know, that program again is key because that's how you audit and monitor your performance as an organization.

SPEAKER_02 8:32

So one of the items, it was actually number eight, Shannon, is is not a federal DME standard. It it was actually a CHAP standard uh revolving around uh thou shalt have a compliance program. Um and I, you know, this is this is pretty new in the last couple of years. We did uh implement or or uh uh you know insert uh specific standards for compliance programs. Um and you know, I I I'm not surprised to see uh one of the standards there. And and actually I'm really glad that we inserted compliance program standards because looking at all of um the scrutiny that is being showered upon DME, um, I think it's more important than ever that uh suppliers and providers have a compliance program. So um when you when you interact with provider Shannon and you're looking at um post-survey stuff, uh when we talk about compliance standards and compliance programs, um what comes to mind for you? Well the importance of it or um uh your thoughts on that?

SPEAKER_01 9:52

Well, I mean the OIG recommended years ago, right, that that all healthcare uh organizations implement a compliance program. And if organizations go to the OIG website, they will find um the OIG's compliance plan, right, for the year. And you can even pull it up specific to DemiPost. Um so following the OIG's um seven elements, right, of compliance is really how CHAP forms um you know their recommendations for the compliance plan. That's where these standards are based. Um so again, following the OIG's compliance program, establishing that compliance officer and that compliance committee to oversee policy and procedure implementation, you know, making sure that everything is applied across the board in fairness, as well as having that auditing and monitoring program to identify fraud and abuse. Um, you know, doing that risk assessment annually to ensure that you know, again, where your opportunities for improvement, where your risk lies as an organization. And that cannot be stressed enough, right? From a fraud and abuse perspective. Um, you know, CMS has come through with this final rule and they tell us that the primary reason for that is fraud and abuse. So it's extremely important that organizations educate their staff, um, that they give their staff the power, right, to act and to report, and and that they take those reports seriously and that they investigate each report and validate the accuracy of that information.

Top Safety Gaps In DME Operations

SPEAKER_00 11:30

I completely agree. I have to tell you, with all of the the top 10, most of which um surround health and safety, which is what we would expect to see in in accreditation survey, um, CP7, I actually applauded the fact that um that it's here so that we can discuss it because as Shannon pointed out, and you have as well, Jen, that you know, the focus on fraud and abuse, and again, we don't we are not government auditors, meaning we do not audit claims, we do not audit, you know, for payment, but having the infrastructure, the importance of the infrastructure of a corporate compliance program with that risk assessment is extremely important. And I applaud you, Jen, for Jennifer, for having the uh foresight a few years ago to put this into our um our you know, into our accredited um service lines because it um it it has been important, um, it's even more important, and it's a really a protection for the provider to have it in place.

SPEAKER_02 12:35

Absolutely, and it's it's taking the compliance high road all the time, you know, and that program helps you identify any kind of potential or real fraud and abuse and helps you process it so that you're back in the in the zone of compliance that you need to be in, right? I'm gonna put Shannon on the spot uh to talk a little bit about some of the um key trends and um suggestions uh that came out of that analyzation.

TB Screening, Policy Review, Documentation

SPEAKER_01 13:06

Sure. So um the first one, we have PS1, uh, which is specific to a safety program. And this safety program, um, I'd say this is probably the most commonly cited um finding that we have for demi pose, but the safety program includes um equipment um minimizing safety risks, infections, and hazards for staff and for patients. So this particular standard you know would include things such as tank storage or tank transportation, cleaning the equipment, uh completing maintenance on the equipment, maintenance and repair, fire extinguishers, right? Whether they're in the uh facility itself or on the delivery vehicles. And personal protective equipment, those are just some examples of things that would go under this particular standard. So, again, not surprising that it's the most common, commonly cited standard. Um, because again, all of those daily tasks, right, that surround any post, uh, whether it's equipment or personnel or patient related, again, looking at infections, hazards, and risks uh for all of those. So that's definitely the most common standard. Um TB control plan. Again, organizations need to refer to their state regulations, right? Most state most states have specific regulations for TB. You can go to the um is it health, the health department website uh for most states and find those regulations. If the state does not have specific regulations, then you always want to refer to CDC guidance. Um but this particular standard at IC3 is specific to screening and testing of personnel. So you want to do that up on higher and and then um you know annually thereafter. And again, that's screening and testing. So we know CDC changed their guidance a few years ago. Um, but again, it's important. I think Jennifer's already mentioned that looking at policy and procedure on a routine basis, right, to ensure that the policy, nothing's changed, right? That nothing is revised, um, specific to state regulations, CDC guidance or federal guidance for that matter. But again, having that routine uh review and monitoring of those policies and procedures, you know, whether you do that through your compliance committee, right, or your QuAPI committee, or or however as an organization you determine to do that. But again, that review of regulation and alliance with policy is extremely important.

SPEAKER_02 15:44

Looks like there were some um documentation issues in, you know, cross sort of across the board. It's is maybe the organization, you know, did do what they were supposed to do, but they didn't document it adequately, so it didn't come through as them being compliant. So um I I see that as uh an area uh for improvement. And then, you know, hand in hand with that is the um the oversight, the leadership oversight to ensure the document not only is a process being followed and you're being compliant, but also um is it being documented. All that sort of falls under um that category as well. Anything to expand on that, Shannon?

SPEAKER_01 16:28

No, you're right. I mean, documentation, organizations, a lot of times we see that they, you know, during the interview process, right? We can determine that they maybe have identified an opportunity for improvement and that they have actually improved, like whether it's through patient satisfaction, record audits, whatever it may be, but they didn't document it. Um or they provided staff training, but yet again, didn't document it. Um, or whether it's a staff competency. I mean, there's all kinds of things that organizations do, but they need to take credit, right, for what they do. Take credit for what they do, put it in black and white. Um, again, I know when I was in operations, staff probably, well, I not probably, I know that they got sick of hearing me say this, that basically if it's not in black and white, it did not happen, right? So if you didn't document it, then it didn't happen. You have no proof that you've done it. So organizations, again, you know, pay attention and be sure that you document and take credit for what you're doing on a daily basis.

Training vs Competency And Multi‑Site Consistency

SPEAKER_00 17:30

And you know what? I would just add on to that. With um for a one location provider, it's one thing to make sure that you have all of those processes documented, reviewed, all the policies, staff are trained, everybody is, you know, to the best of your ability in compliance with the demonstrating compliance with the right the standard. When you have a location or an organization that has multiple locations, you must make sure that that uh consistency, that compliance, that implementation flows all the way to all of your locations. Because you, you know, you'll be sight, you know, they will be cited, even if you have a wonderful policy, you know, at the at the parent organization or at some of your primary locations, if you are surveyed at a at another location under that parent, then you will end up with uh you will have findings. And sometimes that happens with change of staff, um, you know, that have or change in leadership. So really being attuned when you have more than one location, um, that that everyone is uh is really uh in the same readiness mode, if you will, and has the same understanding and everything is updated.

SPEAKER_02 18:52

Absolutely, couldn't agree more. Um I just want to swing back to the oversight and documentation and and competency. You mentioned that, Shannon. I was glad you brought that up. You know, we can educate, but if we don't hold people accountable for uh what we're teaching them, um, that's an oversight issue. If uh we don't tell them um when to document, how to document, uh, et cetera, and not holding them accountable for that, then that's an oversight issue. So um uh it seems to me that uh you know part of the uh when you're looking at this at a bigger um picture, it's um it's it has a lot to do with leadership and oversight, making sure absolutely well, and I think one of the key things that we've seen routinely is organizations understanding the difference between orientation and training and competency, right?

SPEAKER_01 19:51

They're two different things. Competency is a skill assessment, it's where someone is actually observing the personnel perform the skills that they're gonna be doing for patients, uh whether specific to equipment, patient instruction, uh, maintenance, cleaning, whatever it may be, but it is a skill assessment. So it shouldn't just be a checklist that someone's just sitting and documenting and somebody else is signing off one. It's actually an assessment, an observation. Um, and I think that's key is for organizations that understand the difference.

Final Takeaways And New CHAP Tools

SPEAKER_02 20:24

Absolutely key, and and couldn't agree more. Well, it looks like we're getting to the end of our time here together. So I wanted to ask each of you what your final thoughts were for our uh listeners today.

SPEAKER_00 20:38

Well, I can certainly say from my usual gen general comment, you'll hear it every time, uh nothing replaces readiness, survey readiness, oversight, making sure that you have a plan to be able to uh review the standards in real time, uh as uh whether it's your policies, your documentation, record reviews, um, you know, ride-alongs, uh, making sure that you know you are looking at all of your documentation and tracking and competencies and training, as Shannon pointed out, at all levels of the organization. But the other piece I would add is the compliance program, the importance of having a compliance program in place that also is being is implemented in real time to really assist the demi post organizations in particular in ensuring both regulatory and payment compliance, um, and certainly be able to demonstrate those that those efforts toward compliance to CMS should you should you be a subject of an audit or any other type of finding. So, this is one time where I do I strongly recommend both, um, you know, in this case with this environment.

SPEAKER_01 22:00

Absolutely. And of course, your um, you know, your compliance and and your coffee committees, they should be working hand in hand, right? Smaller organizations, it may be some of the same people, larger organizations, you know, it will be different. Um, but both of those um have a role, right, in auditing and monitoring, and of course, the organization should be strategic, right, and their plan uh for auditing and monitoring, identifying the risks, um, and then auditing and monitoring for opportunities for improvement. And of course, when chat comes in um or any accrediting organization, then we're really an extension of that program, a third set of eyes coming in to identify opportunities for improvement for the organization. Um, you know, we see our organizations as our partners, right? And we want them to be successful. So again, as Kim has already said, maintaining that state of readiness. And as we have mentioned, document. If it's not in black and white, didn't happen.

SPEAKER_02 23:00

I hear you. Well, shortly after I uh passed my nursing board, someone gave me a little plaque that said, on on the eighth day, God documented. So Amy, a fellow nurse that gave me that, and I have had it ever since. Uh I just wanted to mention um some exciting tools that we are pushing out with the top 10 DME deficiencies. As I mentioned before, you know, we're giving you the list, but we're also giving you an analyzation of that list uh with rationale for the standard, uh, a key action list as well as suggestions for performance improvement. And then we also this year developed a three-year comparison grid for you that is comparing 23, 24, and 2025 uh top uh 10 DME survey deficiencies, again with analyzation and um overall impressions of the three-year grid. So uh we're really excited to be able to push those out the door and just let you know that um there will be many more DME resources uh coming your way in 2026. So uh Kim and Shannon, thank you so much for talking DME uh with us today. And um thank you to all of you uh for joining our uh chap cast today about the top 10 DME survey deficiencies for 2025. So from Kim and Shannon and me and the entire CHAP staff, keep turning the corner on better performance, stay safe and well, and thanks for all you do.