Decoding DMEPOS Quality Standards, Part 3 – Consumer Service and Personnel Management
By Kris Ravotti, RRT, RCP, Senior Clinical Compliance Educator
Kris Ravotti serves as a senior clinical compliance educator for DMEPOS, Sleep, Pharmacy, and Dentistry Accreditation Programs at ACHC. A passionate advocate for survey preparedness, Kris is a regular contributor to ACHC’s knowledge bank of FAQs and articles. She also develops audit tools and other materials to support providers on the path to continuing compliance.
Posted: August 3, 2026
Now that CMS requires annual accreditation surveys to ensure DMEPOS suppliers remain compliant with the DMEPOS Quality Standards, it is more important than ever that suppliers fully understand these requirements and how they apply to their daily operations.
This article is the third in a series that reviews key components of the CMS DMEPOS Quality Standards and ACHC DMEPOS Accreditation requirements to help suppliers better understand their responsibilities and the importance of maintaining continuous compliance. In Part 3, we cover the key components of consumer service and personnel management.
Consumer service management
DMEPOS Quality Standards require suppliers to investigate any incident, injury, or infection to which DMEPOS may have contributed. The investigation must:
1. Be initiated within 24 hours of becoming aware of an incident, injury, or infection resulting in a client’s/patient’s hospitalization or death.
2. Be initiated within 72 hours of being made aware of all other incidents, injuries, or infections.
3. Include all necessary information, pertinent conclusions about what happened, and whether changes in systems or processes are needed. Consider possible links between the equipment, items, and services furnished and the adverse event.
Other DMEPOS Quality Standards related to safety require suppliers to:
1. Have a contingency plan enabling response to emergencies and disasters or to have arrangements with alternative suppliers in the event the supplier cannot service its own clients/patients as the result of an emergency or disaster.
2. Implement a program that promotes the safe use of products and minimizes safety risks, infections, and hazards for both personnel and clients/patients.
DMEPOS suppliers must also maintain accurate, pertinent, accessible, confidential, and secure client/patient records, as required by the Health Insurance Portability and Accountability Act (HIPAA) and applicable state standards. This includes tasks such as:
1. Reviewing the client/patient record as appropriate for inclusion of information related to the conditions that affect the provision of products and related services, or to the actual equipment, items, and services provided. Suppliers consult the prescriber as needed to confirm the order or recommend any necessary changes, refinements, or additional evaluations to the prescribed equipment, item(s), and/or service(s).
2. Ensuring the DMEPOS prescription and pertinent documentation from the prescriber are kept unaltered in the client’s/patient’s record.
3. Documenting in the client’s/patient’s record the make and model number or any other identifier of any non-custom equipment and/or item(s) provided and verified proof of receipt.
4. Providing essential contact information for rental equipment and options for clients/patients/caregivers to rent or purchase equipment and/or item(s), when applicable.
5. Notifying the prescriber or other healthcare team members promptly, within five calendar days, if the supplier cannot provide the product/service prescribed for the client/patient.
Personnel management
When it comes to personnel, the DMEPOS Quality Standards require suppliers to:
1. Implement policies and issue job descriptions that specify personnel qualifications, training, certifications/licensures, experience, and continuing education requirements consistent with the specialized equipment, items, and services provided to clients/patients.
2. Provide copies of policies, job descriptions, and certifications/licensures to accreditation organizations and government officials or their authorized agents upon request. Personnel must function within the scope of practice as required by the state regulations under which the professional is licensed, certified, or registered.
3. Verify and maintain copies of licenses, registrations, certifications, and competencies for personnel who provide client/patient services.
4. Follow separate requirements for Complex Rehabilitative and Assistive Technology suppliers.
- There are very specific requirements for Complex Rehabilitative and Assistive Technology suppliers. Refer to Appendices B and C of the DMEPOS Quality Standards for details.
NOTE: Remember the importance of documenting that requirements have been met. Without documentation, there may be no evidence of completion.
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Discover more articles about DMEPOS Accreditation here.