Accreditation

Let’s get acquainted.

Reach out to a Customer Experience Specialist to discuss your organization and gain access to an electronic copy of the relevant accreditation manual.

Create and account and start your application.

Your personal Account Advisor will help you with your first login to Compass. Your completed organization profile, attached required documentation, and accreditation fee are all part of the application process.

If yours is a new organization—that is, newly constructed or opened—contact us to discuss the minimum number of patients that must be seen prior to scheduling a survey. Reach us at (855) 937-2242 or email [email protected]

Once your application is processed, a survey team with the relevant experience is built and the onsite survey is scheduled.

The onsite survey

Your Account Advisor will let you know how many surveyors to expect and how long the survey will be.
Deemed status surveys are unannounced. “Accreditation only” surveys (without deemed status) are scheduled in cooperation with the applicant organization.

Surveys are usually scheduled within 90 days of receipt of the completed application and payment. (An accelerated process is available through the TIME program. Contact us for more information.)

All surveys begin with an opening conference to orient your time to the agenda that will be followed and to give your team the opportunity to introduce your organization.

Surveys end with a closing conference that summarizes what the surveyor/survey team observed and the preliminary findings.
After the survey, the information gathered by the surveyors is forwarded to the ACHC office for review.

Your post-survey actions

A Deficiency Report is available within 10 working days of the end of the survey. Your organization then has 10 calendar days (from receipt of the Deficiency Report) to submit a Plan of Correction (PoC)/ Corrective Action Report (CAR) for each non-compliant standard.

Once all POC/CAR have been accepted, a recommendation regarding accreditation is forwarded for a decision.

NOTE: A Deemed Status Survey that results in a CMS condition-level deficiency is subject to resurvey after the organization’s PoC has been accepted in order to confirm that the deficiency has been corrected. This survey is unannounced. Once it has been determined that the facility is in full compliance with all relevant conditions, HFAP will make an accreditation decision.

Accreditation Decision
There are 3 decision options:

Accreditation indicates that the organization has demonstrated compliance with the standards and accreditation is awarded for three years with a resurvey required within one, two, or three years as specified in the decision letter.

Denial of Accreditation indicates that on an Initial Survey, the applicant organization has failed to demonstrate compliance with one or more CMS Condition(s) or has failed to meet other program requirements.

Revocation of Accreditation indicates that a currently accredited organization has failed to demonstrate compliance with one or more CMS Condition(s) or has failed to meet other program requirements.