What is HFAP?
What types of facilities does HFAP accredit?
Who recognizes HFAP?
What is the basis for HFAP accreditation standards?
How are the HFAP standards developed?
What are the major steps in the HFAP accreditation process?
How long does it take to be accredited by HFAP?
Can we switch our facility’s accreditation to HFAP without interruption in our Medicare reimbursement?
How do I apply for accreditation and/or certification?
How do I apply for reaccreditation and/or recertification?

What is HFAP?

Healthcare Facilities Accreditation Program (HFAP) is one of only four national voluntary accreditation organizations authorized by the Centers for Medicare and Medicaid Services (CMS) to survey acute care hospitals, critical access hospitals, and ambulatory surgical centers for compliance with the Medicare Conditions of Participation and Conditions for Coverage.

Originally created in 1945 to conduct an objective review of services provided by osteopathic hospitals, HFAP has become a recognized and sought after accreditor for all hospitals. HFAP has maintained its deeming authority continuously since the inception of CMS in 1965 and meets or exceeds the standards required by CMS.

What types of facilities does HFAP accredit?

The HFAP accredits and crosswalks to CMS standards (as applicable) for the following programs:

• Hospitals and their clinical laboratories
• Ambulatory care/surgical facilities
• Mental health facilities
• Substance abuse facilities
• Physical rehabilitation facilities
• Clinical laboratories
• Critical access hospitals

The HFAP provides certification in the following disease management programs/Centers of Excellence:

• Primary Stroke Center Certification

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Who recognizes HFAP?

In addition to its deeming authority from the Centers for Medicare and Medicaid Services (CMS), HFAP also is recognized by:

• National Committee for Quality Assurance (NCQA)
• Accreditation Council for Graduate Medical Education (ACGME)
• State Departments of Public Health
• Managed care organizations
• Insurance companies

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What is the basis for HFAP survey standards?

• Medicare Conditions of Participation
• National Fire Protection Association (NFPA) Life Safety Code
• Institute for Healthcare Improvement
• Agency for Healthcare Research & Quality (AHRQ)
• National Quality Forum
• Non-Medicare quality standards that include input from our accredited organizations

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How are the HFAP accreditation standards developed?

The basis of the HFAP standards is the Medicare Conditions of Participation (CoPs) for the type of facility being accredited. The standards are cross-walked to the CoPs.  This cross-walk approach means anyone reading the HFAP standards manual can see clearly how each standard ties directly to the Medicare requirements.

HFAP standards are composed primarily of the Medicare requirements plus standards proven to elevate quality and patient safety.  Approximately 80% of the HFAP standards are cross-walked to the Medicare CoPs.

Compliance with HFAP requirements assures compliance with Medicare standards.

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What are the steps in the HFAP accreditation process?

While the actual steps may vary depending on your situation, they include:

• Application
• Survey
• Deficiency report
• Plan of corrections/Corrective action response
• Accreditation action

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How long does it take to become accredited by HFAP?

From application to accreditation, the process can take from three to six months to complete. The four basic factors that impact how long the accreditation process actually will take are:

• The size and complexity of the facility
• Whether it is a new facility or one reapplying for accreditation
• The scheduling of the survey
• How quickly the facility corrects the deficiencies identified in the survey

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Can we switch our facility’s accreditation to HFAP without interruption in our Medicare reimbursement?

Yes. If you are considering switching your accreditation to HFAP our staff will work with you to ensure there is no interruption in accreditation or reimbursement.

Ideally, we would like to begin the application process at least six months prior to the expiration date of your current accreditation. If your current accreditation is due to expire soon here is how the process works to keep your facility in compliance:

• Notify your current accreditation organization in writing as soon as your facility's management has made its decision.
• Work out a plan with your current accreditation organization for an orderly transition.
• If your facility and accreditation organization cannot agree on a plan and the accreditation organization immediately withdraws its accreditation, your facility’s Medicare provider agreement is not affected.
• The current accreditation organization must notify the CMS Central Office and applicable Regional Office that it has withdrawn its accreditation and the effective date.
• If your facility’s termination by the current accreditation organization is concurrent with a new recommendation for accreditation, with deemed status by HFAP, then it may remain under HFAP rather than transfer to the State Survey Agency jurisdiction.
• If your facility’s termination by the current accreditation organization is NOT concurrent with a new recommendation for accreditation, with deemed status by HFAP, your facility is placed under State Survey Agency jurisdiction until the CMS central office and appropriate regional offices receive and approve a new recommendation for accreditation, with deemed status by HFAP.
• When your facility’s accreditation and deemed status is reestablished it is placed under HFAP for ongoing monitoring and oversight.

Whether concurrent transition or non concurrent transition(from your present accreditation organization to the State Survey Agency and then to HFAP), there is no interruption in the Medicare provider agreement and no break in Medicare reimbursement.

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