Q: What does CHAP do for me?
A: CHAP provides the Standards of Excellence, a set of performance standards for community based care organizations, as well as tools (self study, Plan of Correction, webinars, telephone standards interpretation) to assist with learning and understanding CHAP standards and evaluating your organization against the standards. CHAP provides objective feedback on performance against the standards from industry experts, delivered in a way to expand understanding. CHAP provides a dedicated Customer Relations Representative to usher you through the accreditation process and delivers an accreditation that is accepted by payers and approved by the Centers for Medicare and Medicaid Services (CMS). This accreditation serves as a tangible testimony of your organization’s desire to perform at the highest level.
Q: How long does it take to get accredited?
A: The length of time varies by organization, however CHAP suggests that organizations allow 9 months to complete the accreditation process.
Q: How long does it take to receive a CCN (Medicare Certification Number for home health or hospice)?
A: As soon as an accreditation determination has been made, CHAP sends the required survey and accreditation documents to CMS. The CCN is actually assigned by CMS and the time frame varies. It is best to check with the FI/MAC who processed your 855A about status and timing. CHAP suggests organizations plan on at least a 2 month waiting period before receiving their CCN. All requirements of the provider agreement must be met before the CCN is assigned by CMS.
Q: Which forms, policies, and consultants can CHAP suggest I use to assist in my accreditation?
A: The broad descriptive, not prescriptive, approach CHAP takes to accreditation also indicates that there is no one set of policies or one approach to forms that will ensure success. There are many commercial sources of policies and forms and CHAP encourages organizations to select with care. It is important to remember that all tools need to be customized to reflect the specific policies of the organization and how that organization is meeting accreditation standards. CHAP neither endorses nor recommends tools or consultants; we recommend checking with your state home care association for recommendations or doing an internet search.
Q: What is the self study?
A: The self study is a process of examining each standard and understanding its meaning and intent then assessing how the community based care organization meets the standard or determining actions needed by the organization to come into compliance. It is an excellent way for the organization to learn and understand the standards. The self study can be used as a work plan to ensure compliance with all standards. The organization needs to state YES or NA to all self study questions in order to submit. The self study is a web based tool that tracks your progress as you move through the application and allows you to attach electronic documents when required.
Q: How long does it take to have my Site Visit, how long does the Site Visit last, and what happens during the Site Visit?
A: Site Visits are scheduled as soon as the self study is submitted and all other readiness requirements are met. While usually unannounced, Site Visits are planned to occur within 30 - 90 days. The Site Visit begins with an Entrance Conference so that the Site Visitor(s) can introduce themselves and collaborate with the organization on a “game plan” for the Visit. A variety of documents will be requested for review including personnel files, consumer/clinical records, policy and procedure manuals, and meeting minutes. Interviews with management and staff will be arranged and observations in the workplace as well as direct consumer/client service (home visit, home delivery, compounding). The length of the Site Visit varies depending on the size of the organization. The Site Visit is the time when CHAP evaluates the evidence of compliance with the Standards of Excellence. CHAP Site Visitors approach the Site Visit from a consultative and educational, not punitive, perspective.
Q: How long does it take to get a final accreditation determination?
A: The final accreditation determination is made by CHAP’s Board of Review (BOR) after review of evidence from the Site Visit, the organization’s Plan of Correction (POC) has been accepted, and the input and recommendation of the Site Visitor and CHAP Management staff. The Plan of Correction, which may be required due to any Required Actions (deficient practices) found on the Site Visit, must be accepted in order for the Board of Review to consider accreditation. Allowing time for the POC, the BOR will typically make an accreditation determination within 30 days of the Site Visit, with final written notification of accreditation within 60 days of the Site Visit. Organizations that quickly complete an acceptable POC will lessen the time to final accreditation.
Q: If I am interested in deemed status accreditation for Medicare certification, how do I get started?
A: Once you have obtained your license to provide services in your state, as required, you should begin to complete your 855A right away. This form can be time consuming and detailed to complete and the time it takes to process the form by CMS may be lengthy. You can also begin your application for CHAP accreditation and make sure to identify that you are applying for accreditation with deemed status.
Q: How much extra does it cost to seek accreditation with deemed status?
A: CHAP does not charge extra for the deemed status option. Many organizations find it helpful to consolidate their oversight under one body.
Q: Why does CMS still visit us if we have deemed status or accreditation for DMEPOS?
A: For home health and hospice, CMS selects a small random sample of deemed visits CHAP (and other accrediting organizations) conducts within the year. For these visits, completed within 60 days of CHAP’s visit, the objective is to evaluate the alignment of the findings CHAP made during our site visit with those found by the state surveyor on their visit. If condition level deficiencies are found during the CMS validation visit, the organization will lose its deemed status. The state will then do a follow up survey to verify correction of the condition level deficiencies. Once the condition level deficiency is cleared the organization’s deeming authority will be returned to CHAP.
All providers, including DMEPOS, may have visits at any time from Program Integrity, the Fiscal Intermediary, a CERT, or other entity contracted to CMS for purposes of verifying locations, assessing claims payment and researching other issues related to claims payment, compliance, and fraud and abuse investigations. Consent to these visits is part of an organization’s overall Medicare provider agreement. If your organization receives one of these visits we would appreciate a call or email making us aware of the visit so we can assist you, if necessary.
Q: Why won’t CHAP recommend a consultant or commercially available forms and policy manuals that will help me become accredited?
A: CHAP receives many inquiries to recommend resources to assist providers. There are many excellent external resources and we encourage the use of state and national associations as sources to help in your accreditation. For CHAP to recommend consultants and tools, we would need to have gone through a process of extensive review and quality testing to be certain of the effectiveness of these tools, which is not reasonable considering the high volume of supports available. Also, we are concerned that there would be an unspoken sense of guarantee - by using the tools CHAP recommends, my organization will receive accreditation. As you know, accreditation determination is not met by the tools themselves but how they are built into the structure and process of the organization to provide evidence that the standards are met and support quality outcomes.
Q: I understand it is a very long wait to have my initial site visit for accreditation scheduled. How long?
A: CHAP is current with site visits. We schedule all visits within 1-90 days of all readiness requirements being met.