Readiness

In the accreditation process, it’s important to be prepared. That’s why CHAP works hard to keep customers informed of what will be happening and when.

The Site Visit is a critical step in the accreditation process, which is why CHAP strives to accommodate an organization’s scheduling needs when planning.

However, if a CHAP Site Visitor arrives at an organization and the Site Visit cannot be completed due to a refusal to continue, it is considered aborted/cancelled (terminated without completion). CHAP considers it a serious violation when a Site Visitor arrives at an agency and is prohibited from conducting a Site Visit required by CMS and/or the CHAP Board of Review.

Here’s what you should do to prevent an aborted Site Visit:

• Notify your Accreditation Specialist should your active patient count fall below the required needed for an Initial Site Visit (see grid below). We would remove your organization from the schedule and ask that you re-submit readiness once you have met the required active patient count again.
• Organizations anticipating a Renewal Site Visit can request up to 15 black-out dates (subject to approval). All renewal surveys are mandated by CMS to occur within 32-36 months of the last comprehensive survey. Organizations can request blackout dates through CHAPLinQ.
• Please read the CHAP accreditation letter very carefully. If a focus visit is required after a Site Visit, you will be notified in the CHAP accreditation letter. Organizations anticipating a focus visit should contact their CHAP Accreditation Specialist with as much advance notice as possible to request blackout dates (subject to approval). Organizations can also request blackout dates through CHAPLinQ.
• Please ensure that you have the appropriate staff available to meet the CHAP Site Visitor to begin the survey. Once the CHAP Site Visitor arrives onsite and no one is present at your agency, they are only required to wait an hour for agency staff to arrive and begin.

If an organization received findings on their previous survey and have no active patients or additional documentation to review since the last Site Visit, the finding cannot be “cleared.” The original finding will remain and a subsequent survey may occur.

Agencies applying for initial accreditation must meet census requirements in order to be ready for a Site Visit. If they do not, the Site Visit is cancelled with fee.

For all organizations seeking Initial Accreditation, a fee of $3,000 for a site visit that is cancelled while on-site. For all other site visits, a $2,200 site visit fee will be charged for any aborted site visits at the discretion of the Director of Accreditation. The figure allows CHAP to cover the travel and expenses for our Site Visitors and is not meant to be punitive in nature.

Download specific service line documents that may be requested by your site visitor on the corresponding Service page.