CHAP Policies and Procedures

CHAP Accreditation Policies and Procedures

1.    Accreditation determinations

a.    Accreditation is a process, not an event.  The detailed process is described on CHAP’s website at  CHAP offers full accreditation.  The following determinations are made: 

b.    Accreditation without Required Action-full accreditation awarded;  no deficient practices were cited

c.    Accreditation with Required Action-full accreditation awarded;  deficient practices cited for which an acceptable Plan of Correction has been developed

d.    Accreditation with Required Action and a focus visit-a focus visit is required by the Board of Review within 12 months of the Site Visit to follow up on improvement activities implemented in the organization

e.    Other determinations

i.    Deferred and denied accreditation-organization has completed the accreditation process through and including a Site Visit and Plan of Correction;  but is determined by the Board of Review to not be demonstrating substantial compliance with CHAP Standards of Excellence, or having such a large number and type of Required Actions that accreditation cannot be granted.  Only organizations seeking initial accreditation may receive this determination. After deferral, the organization is encouraged to implement the Plan of Correction, and within 6 months, notify CHAP of its readiness for another Site Visit. At this time, the successful organization will receive an accreditation determination as noted above. The unsuccessful organization will be denied accreditation, and may reapply after one year with CHAP, or may seek accreditation from another CMS approved Accrediting Organization, if seeking Medicare approval. 

ii.    Formal warning-issued by the Board of Review to an organization seeking renewal of accreditation. Site Visit and Plan of Correction results lead the Board of Review to warn the organization that performance trends indicate a risk of termination of accreditation.  A warning is issued in advance of any termination of accreditation related to performance or standards compliance.

iii.    Termination of accreditation-removal of accreditation by CHAP for trends of worsening performance as evidenced by Site Visit, or for failure to pay fees as required in the Accreditation Services Agreement. 

iv.    Withdrawal of accreditation-voluntary termination of accreditation by the organization. Must be communicated in writing;  accreditation will end at the end of the 3 year accreditation period, or immediately, unless fees are in good standing as required by the Accreditation Services Agreement. 

2.    Communication

a.    Timely and effective communication is critical to a positive accreditation partnership.  Each organization who executes an Accreditation Services Agreement with CHAP is assigned a Customer  Relations Representative (CRR) who serves as the primary contact person with CHAP, and a Regional Director Of Professional Services (RDPS), who supervises Site Visitors, oversees the accreditation process, and provides Standards of Excellence interpretation where requested. 

b.    Changes of ownership, new or changed location(s), adding or terminating services or products, changes to address, phone number, key contact person and email address must be reported in writing to CHAP within 30 days of the change. These and other written communications may be made by email or regular mail addressed to your CRR.

c.    Scheduling “black out” dates may be communicated to In the rare instance that CHAP cannot accommodate requests, scheduling will contact the organization to discuss.

d.    Compliments or complaints may be communicated here.

e.    Written notice of a request for executive review of a standards dispute, and written requests for reconsiderations or appeals of accreditation determinations may be communicated in writing via email or regular mail to your RDPS. 

3.    Complaints

Accredited providers are required by the Standards of Excellence to provide the CHAP toll free phone number to all of its clients with information on how and when to contact CHAP if they wish to file a complaint against the organization. CHAP investigates all complaints.  Some complaints require a verbal response from the organization, others a written response, and others require a site visit.  Participation and cooperation in complaint investigation and resolution is required. The results of a complaint investigation may adversely affect an organization’s accreditation.

CHAP also wants accredited organizations to feel free to note complaints and compliments about CHAP services or staff.  Complaints are taken seriously as opportunities for improvement, and are documented, tracked and trended, with corrective actions determined and reviewed by management and the Board of Directors.  Complaints can be filed by telephone or via email.  Actions taken to resolve complaints which involved staff counseling are confidential. Compliments are also documented, publicly and privately acknowledged.  Both are incorporated into ongoing customer satisfaction monitoring and improvement. 

5.    Customer satisfaction

Is very important to CHAP.  Upon exit, the Site Visitor will request feedback on the Site Visit experience, and will provide the organization with a form to document this feedback.  After the accreditation decision is rendered, CHAP will forward a formal Customer Satisfaction Survey to the organization.  Results are documented, tracked and trended, and analyzed by management and the Board of Directors for improvement actions.

6.    Fees and payments

a.    Are set based on the number of locations, the number of services and the annual volume within each service applying for accreditation. All fees are due within 30 days of invoice.  Payments must be current in order for a site visit to be scheduled.  Non-payment of fees may negatively affect accreditation, up to and including termination of accreditation.  Fee disputes must be made in writing within 30 days of the invoice.  

b.    The Accreditation Services Agreement with CHAP defines the annual accreditation fees and the estimated number of site visit days for which the organization is responsible. 

7.    Fraud, abuse and ethical issues

Investigating billing integrity through detailed investigation is beyond the scope of the accreditation process.  The Standards of Excellence do include requirements to follow sound business practices, address conflicts of interest, and respect patient rights.   Site Visitors will provide education about compliance plans and strengthening strategies.  If CHAP identifies trends of issues that indicate intent or indicate significant concerns of fraud and abuse within a Medicare certified agency, CHAP is required to report to CMS persuant to Section 1921 of the Social Security Act.  Accreditation terminations from CHAP are reported as required add the to the National Practitioner Data Base. 

8.    Legal entity

The basic requirement of eligibility for accreditation.  The organization must obtain any licenses required by the state(s) in which the services they seek to accredit are provided. 

9.    Performance improvement

Is a continuous series of actions to plan, measure, evaluate and improve the outcomes of the organization.  A performance improvement plan and program is required of every CHAP accredited organization. 

10.  Plan of correction

Is required for all Required Actions (citations of deficient practice) identified on a CHAP site visit.  These include CHAP Required Actions as well as CMS deficiencies, if applicable.  An acceptable Plan of Correction if required for the organization’s visit results to be presented to the Board of Review for a final accreditation determination.  Follow up visits will focus on the implementation of the POC and its effectiveness in correcting deficient practices

11.  Reconsiderations and appeals

a.    Organizations experiencing concerns or issues about their site visit or accreditation determination have alternatives.

b.    For disputes including issues about specific issues of the site visit, contact CHAP management by phone during the Site Visit.  Issues will be addressed orally during the site visit.

c.    For disputes about specific citations, address in writing during the Plan of Correction process, included with response to the specific citation. Additional documentation may be provided via email.  Responses will be provided in writing within 10 days of receipt of the Plan of Correction.

d.    Disputes may be escalated to Executive Management upon request. A written response will be provided within 30 days.

e.    For disputes regarding an accreditation determination, request a reconsideration in writing, and provide additional documentation for consideration.  An additional Board of Review will occur, and a written response will be provided within 30 days.

f.    For disputes regarding an accreditation determination following a reconsideration, request an appeal in writing, and provide additional documentation for consideration.  The CHAP CEO will convene a committee of the Board of Directors for a final review, and a decision will be provided in writing within 30 days.  

12.    Scheduling

Of initial site visits occur after all readiness requirements are met.  These are specified below[l4] .  Site visits will occur within 1-4 months after all readiness requirements are met.  All CMS related and deemed visits are unannounced.  All other visits are coordinated with the organization. Organizations are encouraged to provide “black out” dates when key personnel absences or key organizational activities make an accreditation site visit difficult. CHAP will accommodate these requests as much as possible, but site visits can rarely go beyond 36 months since the previous visit without incurring risk of termination of accreditation.  These instances must be approved in a written extension of accreditation from CHAP.

13.    Site visits

a.    Are an essential component of the accreditation process.  Site visitors are assigned to survey service lines in which they have at least 5 years of experience at the mid to upper management level.  Site visitors are never assigned to any organization with whom they have any conflict of interest.  A site visit begins with an entrance conference, in which the site visitors introduce themselves, and discuss the plan for the visit. A daily debriefing is conducted at the end of each day, and the visit concludes with an exit conference at which the site visitor will verbally inform the organization of deficiencies cited and their recommendation to the Board of Review regarding accreditation. 

b.    Are conducted within 1-4 months of an organization seeking initial accreditation submitting a completed self study and notifying CHAP that all other readiness requirements are met

c.    Are conducted within 1-4 months of self study submission for organizations seeking renewal of accreditation

14.   Commendations:

Commendations may be recommended by the Site Visitor and awarded by the Board of Review for organizations where all elements of a standard are met, AND the organization demonstrates a best practice, or program that exemplify organization efforts above and beyond any accreditation or regulatory standard to define and advance the quality of community-based care.

15.   Change of Ownership (CHOW):

Change of Ownership (CHOW) applies when the purchase or transfer of stock or assets arises to 51% or more resulting in a change in management control.  Organizations considering selling or buying an organization which is already CHAP accredited, or needs to be CHAP accredited,  should contact CHAP to review their situation and get guidance.  CHAP will provide organizations a form to  provide information about the buyer, and seller, confirm filing of CMS 855A or S, as required, and commit to operating the location in accordance with CHAP Standards of Excellence.  In addition, all accreditation fees must be current in order for the accreditation of the service to transfer to the new owner. A follow up on site visit will occur within 4-6 months of the close of the change of ownership transaction.  Changes of ownership should be communicated to CHAP as soon as possible and no later than 30 days after the execution of the sale to avoid interruptions or termination of accreditation.  CHAP staff will maintain information about changes of ownership confidential. 

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