The Accreditation Commission for Health Care (ACHC) recently published its annual list of most frequently cited sleep lab deficiencies during its accreditation surveys performed between June 1, 2022, and May 31, 2023. 

Last year I noted that an uptick in deficiencies might’ve resulted from sleep labs aiming for quick reopening or rapid pivots to home-based testing as the COVID-19 pandemic waned,” said ACHC’s senior program director Tim Safley, MBA, in The Surveyer newsletter. “This year’s survey volume was even higher, but overwhelmingly, the organization of the testing centers and labs surveyed and their attention to delivering safe, high-quality services was impressive.” 

Still, Safely adds, “Just because we’ve seeing progress doesn’t mean we lose vigilance in the quest for continuous quality improvement!”

[Further reading: Sleep Lab Infection Control: A Surveyor’s Insights]

The Requirements Most Cited as Sleep Lab Deficiencies

  1. The standard ensures that an individual record is maintained for each client and that the record contains current and accurate information.  
  2. The sleep lab develops a Performance Improvement Program that includes measurement, analysis, and tracking of meaningful quality indicators and the actions taken when improvement opportunities are identified. 
  3. Sleep lab clients/patients are provided with information that covers how to communicate a grievance/complaint to the organization, relevant state agencies, and ACHC.
  4. 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. 
  5. The sleep lab’s medical director or certified sleep physician provides monthly education for personnel.  
  6. Written policies and procedures address a fire safety plan for all office and worksite environments. 

Examples of ACHC Surveyor Findings

1. The standard ensures that an individual record is maintained for each client and that the record contains current and accurate information. (33% cited)

Surveyors found:

  • Client records did not pre- or post-sleep study questionnaires. 
  • For home sleep study (HST) patients, the type of device used was not noted in the record. 

2. The sleep lab develops a Performance Improvement Program that includes measurement, analysis, and tracking of meaningful quality indicators and the actions taken when improvement opportunities are identified.  (31% cited)

Surveyors found:

  • The semiannual summary did not include reporting adverse events. 
  • The medical director does not receive semiannual PI reports. 

3. Sleep lab clients/patients are provided with information that covers how to communicate a grievance/complaint to the organization, relevant state agencies, and ACHC. (19% cited)

Surveyors found:

  • Written information provided to the client/patient did not include the state regulatory body’s hotline purpose, hours of operation, and telephone number(s). 
  • Home sleep testing clients are not provided with information regarding the grievance process. 

4. 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. (15% cited)

Surveyors found:

  • Personnel files did not include evidence of a National Sex Offender Registry check. 
  • Personnel files did not include evidence of a criminal background check. 

5. The sleep lab’s medical director or certified sleep physician provides monthly education for personnel.  (14% cited)

Surveyors found:

  • Personnel files contain evidence of monthly educational sessions but no evidence that the medical director or certified sleep physician provides or attends the sessions. 
  • The medical director spends time with the day sleep tech and sleep manager each week. But there is no documentation of what is discussed weekly or that a monthly educational session occurs and the night technician has not been included in the weekly discussions. 

6. Written policies and procedures address a fire safety plan for all office and worksite environments.  (12% cited)

Surveyors found:

  • An annual fire drill has not been completed with the night staff. 
  • There is no evidence of fire extinguisher maintenance. 

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