General FAQs
Standards FAQs
Accreditation Survey FAQs
General FAQs
The following chart shows the differences between accreditation and licensure/certification:
|
|
Accreditation Surveys |
State Surveys |
|
Purpose |
Performance improvement; deemed status in some states |
licensure and/or Medicare/Medicaid provider certification |
|
Oversight |
private, not-for profit company |
governmental entity |
|
Compliance |
voluntary |
mandatory |
|
Emphasis |
evaluation |
inspection |
|
Frequency |
triennial |
annual |
|
Notice |
announced |
unannounced |
|
Funding |
provider fees |
tax dollars |
|
Focus |
What is the organization doing right? How can it improve? |
What is the organization doing wrong? |
|
Expectations |
achievable standards |
minimum expectations |
|
Scoring |
systems and processes |
individual deficiencies |
|
Value |
improvement |
enforcement |
|
Process |
survey to standards |
survey to regulations |
|
Approach |
education/consultation |
sanctions/penalties/fines |
|
Findings |
recommendations for improvement |
citations |
|
Award |
accreditation |
licensure or certification |
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With our online Quality Check™, you can "check up" on the performance of health care facilities, by reviewing their latest Quality Report.
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You can complete our online Quality Incident Report Form. For more information, please call 800-994-6610.
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Standards FAQs
Please check our the Standards FAQs section of our website. If you don't find your answer there, you can complete our Online Standards Form or call 630-792-5900.
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Accreditation Survey FAQs
Your organization can normally be surveyed within three to four months after we receive your application. However, the key issue is whether you are ready to be surveyed. We will evaluate the past four months of service for compliance with the standards. If your organization is beginning to prepare for survey at the time of application, it should request to be surveyed at least four to six months later. Your application for survey is valid for 6 months from the date it is submitted.
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This varies considerably from organization to organization and depends on the amount of time and resources available to prepare for survey. Most organizations take one full year from the point of the initial decision to the actual survey date.
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You must be in compliance for four months on an initial survey, one year on a resurvey. We don't expect a track record of compliance for a provisional accreditation survey (early survey option).
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This varies with the number of surveys conducted in the previous month but averages about 45 days. Your organization is retroactively accredited to the day after survey.
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Ambulatory Health Care Facilities: A building or part of a building used to provide services or treatment to four or more patients at the same time that meets the criteria of either (a) or (b) below.
Facilities that provide, on an outpatient basis, treatment for patients incapable of taking action for self-preservation under emergency conditions without assistance from others.
Facilities that provide, on an outpatient basis, surgical treatment requiring general anesthesia.
Example: A surgi-center with three operating rooms and six recovery beds that normally has four or more patients under anesthesia or recovering
All other setting for outpatients are business healthcare occupancy. Example: A primary care clinic where only local anesthetics are used.
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Depending on the services you provide, you may have to complete a Statement of Conditions™. If you give care to four or more patients at the same time that would render them incapable of self-preservation, your organization is considered an ambulatory health care occupancy, and an SOC™ is required. No SOC™ is needed for freestanding business occupancies.
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Yes, as long as your organization meets the general eligibility criteria. However, some states do require state licensure.
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The accredited organization that acquires your organization must inform us within 30 days of beginning operations at a new site or offering new services. Your organization may or may not be surveyed to extend accreditation. We determine this case by case.
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When you make any changes in your organization (new CEO or administrative staff; new services or sites; new owners; new address, state, or zip code) you must notify us within 30 days. Once we receive your notification, we'll update your organization's files to indicate the changes and determine whether to conduct an extension survey.
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Yes. Physician offices are just one of the many types of ambulatory care organizations that we accredit.
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A deemed status survey gives you the opportunity to become accredited and Medicare certified with one survey. To be eligible for a deemed status survey, your organization must be a state-certified ambulatory surgery center. You must specifically select the deemed status option on your survey application. We conduct your deemed status survey at the same time as our regular survey, but the survey is unannounced; you will not be notified of the survey date in advance. We'll add a short paragraph in your official accreditation decision letter to indicate that your organization met the requirements for deemed status. Choosing the deemed status option does not increase your survey fee. For more information about deemed status, see Questions and Answers about Deemed Status for Ambulatory Surgery Centers.
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Contact the Customer Service Center toll free at (877) 223-6866. You can view a catalog of all our publications online.
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