This process provides a step-by-step guide for regaining compliance when a staff scorer fails to meet the ISR requirements outlined in Standard F-7.
If staff fail to meet the required compliance standards for Sleep ISR, the following procedures must be followed:
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Document the Quarterly Compliance Report
- Identify the reasons for non-compliance.
- Propose appropriate resolutions to address the issue.
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Assess the Feasibility of Regaining Compliance
- Determine if the facility will restore compliance by allowing the staff scorer to compensate for the missed ISR record.
- The site director must decide on this course of action, which must be documented in the facility's written policy.
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Selection of a Blind Study
- Choose an overnight polysomnography (PSG) study with 200 epochs for evaluation.
- Ensure the study meets the following criteria:
- Reference Sleep Specialist Involvement: A reference sleep specialist (meeting Standard B-2, such as the facility director or a board-certified medical professional) serves as the benchmark for comparison.
- Independent Scoring: Both the reference sleep specialist and the staff scorer independently score the same 200 epochs.
- Scoring Parameters: The scoring must include:
- Sleep Staging (evaluated epoch-by-epoch)
- Respiratory Events
- Leg Movements
- Arousals
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Agreement Percentage
- Calculate the level of agreement between the staff scorer and the reference sleep specialist, typically expressed as a percentage.
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Comparison Data Tabulation
- Analyze each of the four scoring parameters to determine if the agreement meets the acceptable percentage.
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Outcome Report
- Document whether the staff scorer achieved the required agreement percentage.
- If the standard is not met, detail the corrective actions taken to address discrepancies.
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Final Review and Sign-Off
- The reference sleep specialist must review the final report and sign it, confirming the review process and any corrective actions taken.
- Ensure the report is dated and securely filed for record-keeping.