Accreditation Process

Overview:

At CHAP, we know that the accreditation process can often be complicated, time-consuming and confusing. That is why we have developed a simple 6-step process that is streamlined and easy-to-navigate.

To get started, simply click on Step 1 above and follow the instructions.

And if you need any assistance along the way, we're here to help.

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Step 1 - Application and Contract:

Prerequisites:  The Applicant must be a legal entity licensed as required in all states and cities where the applicant provides services and which are services that CHAP accredits.

Applicant’s Responsibility: The applicant organization completes and submits the application along with the $550 non-refundable application fee and any required documents to CHAP.  Sign and return the CHAP Accreditation Services Agreement along with a check for payment of the first of three annual payments towards accreditation fees*.

CHAP’s Responsibility: Upon receipt of the application, CHAP staff will:

  • Confirm the organization's eligibility for accreditation
  • Review the application for completeness
  • Determine the annual accreditation service fee based on number of locations and number of services to be accredited
  • Estimate the number of site visit days necessary to survey the organization based on Applicant information provided
  • Complete and send two original accreditation service agreements (contracts) to the applicant organization for signature

Post Requisites: When the contracts are signed and returned to the CHAP office, copies of the applicable Standards are forwarded to the applicant organization along with 1 fully executed contract. The contract spells out the duties and responsibilities of the parties and locks in the agreement and fees for a 3 year term.

Average Time to Complete:  10-14 business days for Applicant to receive contracts for signature once application and fee are received.  Within 5-7 business days you should receive the executed contract and the standards.

*Inability to meet the CHAP accreditation standards or a decision to subsequently withdraw from the accreditation process does not relieve applicant from having to make all three accreditation fee installment payments.

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Step 2 - Self Study:

Prerequisites:  A fully executed contract, applicable standards, User Name and password (will be provided via email) to complete the Self Study (communicated by CHAP to the Applicant).

Applicant’s Responsibility: The Self Studies (Core and service-specific) are tools that allow the Applicant to complete a comprehensive internal evaluation of both the business and service aspects of the Applicant’s organization in preparation to meet CHAP Standards of Excellence.  The Self Studies are due in the CHAP office within 3 months of the date of the fully executed contract. Organizations will use the CHAP LinQ Client Portal to complete their Self Study online. For more information on the CHAP LinQ Self Study click here.  Updated Self Studies must be prepared and submitted at the start of each new accreditation cycle.

CHAP’s Responsibility: The Self Study will be reviewed by the assigned site visitor to plan and execute the site visit. 

Post Requisites:  The submission of the Self Study communicates readiness for the on site visit.  The site visit is then assigned and scheduled.

Average Time to Complete:  3 months is assigned in the Accreditation Services Agreement

A written request may be made to extend the due date which CHAP has the sole discretion to grant for a period not to exceed 90 days. 

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Step 3 - Site Visit:

Prerequisites:  Completed Self Study, required patient census and required additional documents

Applicant’s Responsibility: Applicant must be ready for a site visit at any time after the Self Study has been submitted and all other readiness requirements are met.  The Applicant must have the minimum number of active census based on the service to be accredited. In preparation for the Site Visit, these documents will be requested by the Site Visitor as a part of the entrance conference.  At the exit conference, the Applicant will sign a Pre-Bill form which indicates the number of Site Visit days that will be invoiced.  (As an example – 2 site visitors at the agency for 3 days would result in CHAP billing for 6 site visitor days.) The Site Visit will  also include observation and interview of staff in different service site settings.

All site visits to home health and hospice organizations will be unannounced if agency applies for "deemed status." All site visits for home medical equipment (HME) and pharmacy accreditation will be unannounced. For any multi-service organization with a deemed service, the site visit will be unannounced. Visits to other organization types are announced. Board of Review required Focus visits and complaint investigation visits are all unannounced.

CHAP’s Responsibility: Scheduling and assignment of the site visitor(s) within a reasonable timeframe from the receipt of the Self Study and written notification of required patient census and receipt of all required documents.

Post Requisites:  Site visitor(s) will submit to CHAP any required actions identified during the course of the site visit along with the recommendation to the Board of Review regarding accreditation.  The Applicant will await the receipt of the Plan of Correction (POC) which will be emailed to the Applicant within 10 business days from the last day of the site visit.

Average Time to Complete:  The duration of a site visit is generally between 2 to 5 business days based on number of clients served, size on inventory, number of locations and size of geographic area served. 

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Step 4 - Plan of Correction:

Prerequisites:  This step is only applicable if required actions have been identified during the site visit.

CHAP’s Responsibility: The CHAP staff will send the POC to the applicant within 10 business days of the last day of the site visit.

Applicant’s Responsibility: The Applicant logs onto the POC Toolkit and submits the plan for correcting the required actions identified during the CHAP site visit.  The Applicant has 10 calendar days from the date the POC is sent to submit their response to CHAP.

Post Requisites:  If the corrective actions listed in the POC Toolkit are accepted, the Applicant will receive email notification of acceptance. The accepted POC will be presented to the CHAP Board of Review for accreditation determination. If the POC is not accepted, CHAP will email the POC back with the unacceptable areas defined in the email. The applicant must resubmit the POC with the changes requested via email within 5 calendar days. Please see our webinars page for more details on the POC.

Average Time to Complete:  3-4 weeks

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Step 5 - Board of Review (BOR):

Prerequisites:  Accepted Plan of Correction (POC) or a site visit with no required actions.

Applicant’s Responsibility: None

CHAP’s Responsibility: The BOR will review and make an accreditation determination for all site visits completed where the Applicant has submitted an acceptable POC or had no required actions. BOR determinations are made with all organization identifiers removed, and are scheduled once the Plan of Correction has been accepted. 

Post Requisites: Within 4 weeks of the Board of Reviews meeting, a letter regarding the determination to accredit or not, and a copy of the accepted POC will be mailed to the accredited organization.

Average Time to Complete:  6-8 weeks

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Step 6 - Accreditation:

Prerequisites:  

Board of Review determination to accredit.

Applicant’s Responsibility:

Celebrate and continue the process of accreditation and the pursuit of quality and continuous performance improvement.

CHAP’s Responsibility:

The CHAP staff will provide the Applicant a formal letter of accreditation and a certificate of accreditation.  The Applicant will also receive the CHAP Media Kit for to assist in communicating accreditation via the Applicant’s Web site and business collateral.

For deemed agencies, the Applicant’s accreditation letter and all required CMS documentation is sent to CMS.

Post Requisites: 

The accreditation will be posted on the CHAP Web site.  This 6-step process must be repeated every 3 years in order to remain CHAP accredited. 

Average Time to Complete:

1-2 weeks

 


 

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Telephone:

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Fax Number:

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General Contact email:

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