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?

What is HFAP?

Healthcare Facilities Accreditation Program (HFAP) is one of only three national voluntary accreditation programs authorized by the Centers for Medicare and Medicaid Services (CMS) to survey hospitals for compliance with the Medicare Conditions of Participation for Hospitals.

Originally created in 1945 to conduct an objective review of services provided by osteopathic 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.

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

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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
• Additional non-Medicare quality standards
• Suggestions and input from our customers

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How are the HFAP accreditation standards developed?

HFAP standards have been "cross-walked" to the Medicare Conditions of Participation (CoPs) for each type of facility. This cross-walk approach means anyone reading the HFAP standards manual can see clearly how each standard ties directly to a Medicare Conditions.

HFAP standards are composed of all Medicare standards plus standards proven to elevate quality and ensure that the Medicare standards are met (the following is a breakdown of the composition of all HFAP standards):

• All Medicare standards (40%)
• Patient treatment (47%)
• Quality improvement (29%)
• Patient safety (27%)
• Environmental safety (26%)

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
• 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 six to nine 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 speed in which surveyors can be scheduled for 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 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 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 facililty 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 will 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 accredited, 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 accredited, deemed status by HFAP, your facility is placed under State Survey Agency jurisdiction until the CMS central and appropriate regional offices receive and approve a new recommendation for accredited, deemed status by HFAP.
• When your facility’s accredited, deemed status is reestablished it is placed under HFAP for ongoing monitoring and oversight.

Whether concurrent transition or not 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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