Accreditation Process

The contract includes detailed policies and procedures, and spells out duties and responsibilities for both your organization and CHAP.

Requirements

• Accepted application

Your responsibility

• Sign and return contract
• Pay the amount due outlined in the Accreditation Services Agreement payment schedule by check or by credit card

CHAP’s responsibility

• Review and execute contract
• Initialize CHAP Standards of Excellence and Self Study

The CHAP Self Study is there to guide you through a comprehensive self evaluation of the business and service aspects of your organization.

First, you’ll get to know and understand our Standards of Excellence; then you’ll assess how your organization is doing by comparison. Are you meeting the standards, or do you need to make changes?

An added bonus: Many organizations use the Self Study as the foundation for a business plan to ensure ongoing compliance.

Requirements

• Executed contract

Your responsibility

• Review the Standards of Excellence
• Review the Site Readiness Video
• Complete the Self Study
• Upon completion of the Self Study, communicate Site Visit readiness
• Include any changes in the number of active patients/clients
• Request up to 15 “blackout days” on which, CHAP will try to avoid scheduling when possible

CHAP’s responsibility

• Review Self Study and Readiness
• Schedule visit

Want to know MORE about READINESS? Click HERE.

CHAP evaluates your company’s evidence of compliance with our Standards of Excellence, working with you as an educator and coach.

The Site Visit begins with a conference where the Site Visitors introduce themselves and develop a plan for the visit. They will request a variety of documents, including personnel files, consumer/clinical records, policy and procedure manuals, and meeting minutes. Over a few days, they will observe the workplace and care provision, as well as interview management and staff. They will also make home visits to observe services being rendered and to interview clients.

Requirements

• Before a Site Visit can be scheduled, readiness must be submitted in CHAP LinQ.

Your responsibility

• Provide space for the Site Visitor to conduct work, plus documents, files and patient staff lists as requested
• Allow observation and interview of staff, patients and agency leadership in different settings as appropriate

CHAP’s responsibility

• Site Visitor (or lead Site Visitor if more than one) will conduct entrance and exit conferences, along with daily check-ins
• Site Visitor provides a preliminary report of any performance deficiencies and a “pre-bill” form that indicates the number of Site Visit days to be invoiced (e.g., two Site Visitors at the agency for 3 days = 6 total Site Visitor days)

Considerations

• If the Site Visitor is refused entry, the visit is recorded as aborted and the applicant is charged the aborted-visit fee.
• If the applicant is not present to conduct the survey, or failed to notify CHAP in advance that it does not meet census requirements, the applicant is charged the cancellation fee.

If there are any performance deficiencies found during the Site Visit, you will be required to complete a Plan of Correction (POC) to continue your accreditation process.

Requirements

• Completed Site Visit

Your responsibility

• Submit an acceptable POC within 10 calendar days of notification from CHAP Director of Accreditation
• If the Director of Accreditation asks for revisions, the applicant must submit modified POC within 5 calendar days

CHAP’s responsibility

• Director of Accreditation will notify the organization of POC requirement within 10 business days from the last day of the Site Visit
• Director of Accreditation either accepts the POC or requests further modifications
• CHAP will respond to a revised POC within 10 business
• The final acceptable POC will be submitted to CHAP Board of Review

Once the Plan of Correction (POC) is accepted, the Board of Review will assess the Site Visit finding and POC. The CHAP Board of Review is comprised on industry experts and care providers with a track record of successful surveys.

Requirements

• Completed Site Visit with no required actions or accepted POC

Your Responsibility

The Board of Review (BOR) will review the POC (names and identifiers removed) and make one of the following accreditation determinations:

• Accreditation
• Accreditation with required action (POC)
• Accreditation with required action (POC) and follow-up visit within a specified time frame
• Deferred/denied accreditation – organizations with serious deficiencies
• Formal warning – renewing organizations with deficiencies, requires a POC and follow-up visit
• Termination of accreditation – renewing organizations with serious deficiencies they are unable to clear after multiple attempts

CHAP’s Responsibility

• Applicant is notified via e-mail of the determination

Considerations

• An organization may appeal a BOR determination within 10 business days of notification of decision. If applicant remains dissatisfied, a final appeal can be made within 30 days to the CHAP Board of Directors, whose decision is final

Congratulations! Your organization receives full CHAP accreditation!

Your responsibility

• Celebrate your success and continue to pursue ongoing adherence to Standards of Excellence
• Provide free and discounted ongoing professional development for yourself and your team by accessing CHAPEducation resources.

CHAP’s responsibility

• Send formal determination letter and certificate of accreditation via U.S. mail
• Notify CMS of your determination and submit the required forms on your behalf
• Initiate the CHAP Accredited Provider Media Kit for promoting your new accreditation status
• Make your company profile available on the CHAP Find a Provider Portal

Considerations

• The CMS regional office notifies the accredited organization directly regarding Medicare certification
• The CHAP accreditation process is 3 years from the date the final acceptable POC is submitted, or if renewing, from the last day of the previous comprehensive Site Visit