Your first step in the accreditation process is to become familiar with HFAP policies and standards by reviewing the relevant accreditation manual. Currently accredited organizations have free access to an electronic manual and all updates that occur during a term of accreditation. If your organization is new to HFAP, you may order a print copy of the manual here or contact us for access to an electronic copy.
Log in to HFAP Compass to begin. 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 312.920.7383 or email firstname.lastname@example.org.
Once your application is processed, a survey team is created and the onsite survey is scheduled.
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 HFAP TIME program. Contact us for more information.)
Once the survey takes place, the information gathered by the surveyors is forwarded to the HFAP office for review.
A Deficiency Report is available to the applicant organization within 10 working days of the end of the survey. You then have 10 calendar days (from receipt of the Deficiency Report) to submit a Plan of Correction (PoC) for each non-compliant standard.
Once all Plans of Correction 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, in fact, 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.
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.
The decision letter is sent to the organization and, for a Deemed Status Survey, to the CMS Regional Office and the CMS Central Office. A certificate of accreditation is provided to the organization.