2009 CMS Mandated Changes in Accreditation Process

The Centers for Medicare and Medicaid Services (CMS) has required a change to the existing HFAP survey process for accreditation, as of May 8, 2009. HFAP is making this change as a component of our deeming authority responsibility. This new process is effective, beginning with all facilities which have been surveyed as of May 8, 2009 and later.

To this end, the following procedural outline shows the changes (in bold) that have been made to the accreditation process:

• The healthcare facility will undergo a full survey, as in the past;
• The healthcare facility will respond to A, B & C weighted deficiencies within designated time-frames;
• Deficiencies cited as 2, 3, or 4 will require corrective actions;
• These corrective actions will be reviewed for completeness by HFAP staff;
• A healthcare facility that is found to be out of compliance with a Medicare Condition at the time of the initial survey, will under-go an unannounced re-survey, focusing on the area of non-compliance relating to that Condition. In addition, the facility will be responsible for the cost and related expenses for conducting the focused survey;
• The surveyor(s) will submit their report from the focused survey to the HFAP, where it will be reviewed and then sent to the Bureau of Healthcare Facilities Accreditation, for accreditation action;
• Healthcare facilities must be found to be in full compliance with all HFAP A-weighted standards, including all Medicare Conditions prior to accreditation being granted.

The HFAP is committed to delivering a high quality accreditation program in order to assist our customers in maintaining compliance with meeting their obligations outlined in their provider agreement with CMS. Please do not hesitate to call with any questions or concerns relating to the new requirements.