The Accreditation Process
Healthcare facilities may apply for accreditation by completing an application and submitting it with the appropriate registration fee and required documents.
New Facilities-must have at least 20 patient records for the surveyors to review before a survey is scheduled.
The application is processed, a survey team is formed and the survey is scheduled.
All surveys are unannounced.
The surveys are usually scheduled within 90 days of receipt of the complete application and fees.
Once the survey is completed, the information gathered by the surveyors is forwarded to the HFAP office for review.
A formal deficiency report is sent to the facility within 10 working days.
The facility has a period of time to respond and correct any deficiencies cited. A-weighted deficiencies (which include CMS Conditions of Participation (CoP) or an HFAP standard that is deemed to have a serious impact on patient safety/care) must be corrected within 30 days. B-weighted deficiencies (which include CMS standard level and Life Safety Code deficiencies) must be corrected within 60 days. C-weighted standards also must be corrected within 60 days.
A facility that has received a CMS condition level deficiency is subject to resurvey once they have submitted their corrective action and it has been accepted by the Bureau of Healthcare Facilities Accreditation. This survey is unannounced. Once it has been determined that the facility is in compliance with the CoP the Bureau will take accreditation action.
There are 3 levels of accreditation:
- Full Accreditation-with resurvey within 3 years-this indicates that a healthcare facility meets the HFAP accreditation requirements in all performance areas
- Interim Accreditation-indicates that a facility generally meets the standards, but that certain areas have been identified which need additional work to be compliant. Interim accreditation will not exceed 12 months.
- Denial of Accreditation-indicates that a healthcare facility has been denied accreditation because it does not meet HFAP requirements.
The result of the Bureau action; in the form of a letter, is sent to the facility, CMS Regional Office and the CMS Central Office. If the facility has achieved accreditation a certificate of accreditation is also sent to the facility.