CHAP accreditation is designed to be a collaborative, consultative and educational process so you can prioritize providing care.
Before you start the application process, be sure you qualify for accreditation:
- You must be a legal entity.
- You may need to be licensed in all the cities and states where you offer services (if those cities and states require licensing).
- You should offer services CHAP accredits: home health, hospice, home medical equipment, private duty, pharmacy, infusion therapy nursing and public health.
If your organization provides services under an emerging model of health care that does not exactly match those listed above, give us a call or send us an email to learn more about how we may be able to help.
The following questions and answers reflect the type of information our customers have asked as they start on the path to accreditation. If you do not see the information you need, email us or call us at 202.862.3413.
It varies by organization, but you should allow between 6 and 9 months to complete the entire accreditation process. In certain circumstances, we can move faster on this process.
Our approach to accreditation means that there is no one set of policies or one approach to forms that will ensure success. Likewise, we cannot review and quality test all the tools and consultants that might be available to our customers.
Therefore, if you do use commercial sources of policies and forms, we encourage you to select them with care. All tools you use should be customized to reflect the specific policies of your organization.
Accreditation standards are not met by the tools themselves, but by how well the tools are built into the structure and process of your organization so that your business and service operations support quality outcomes.
The Self Study in an online self assessment to be used to help evaluate both the business and service aspects of your organization. It also helps you prepare for the next step of the accreditation process — the Site Visit.
Through the Self Study, you review each of CHAP’s Standards of Excellence, then assess how your organization is meeting the standards.
After this assessment, you’ll develop a “project plan” to address the implementation and consistent application of policies, procedures, practices and protocols to ensure compliance with CHAP standards.
The Site Visit allows us to evaluate the evidence of your compliance with CHAP Standards of Excellence. Our Site Visitors basically perform five activities while they are with you:
- Hold an entrance conference so that they can introduce themselves and work with you to develop a plan for the visit.
- Collect and review documents such as personnel files, consumer and clinical records, policy and procedure manuals, and meeting minutes.
- Observe the workplace, including where direct consumer and client services take place (for example, home visit, home delivery, etc.).
- Interview management and staff.
- Conduct an exit conference to summarize the preliminary findings of the visit and discuss next steps.
Site Visits can be scheduled as soon as you submit the Self Study and have met any other readiness requirements. Site Visits usually take place within 1 to 90 days from when you submit Readiness.
Our Site Visitors are assigned to perform accreditation visits only for services where they have specific experience. They are required to have a minimum of five years of experience in a health care field that reflects the scope of care and services we accredit. Our Site Visitors hold a minimum of a bachelor’s degree in a related specialty area; most have a master’s degree. We also require that they have a minimum of five years of management or executive level experience in a home or community-based health care organization.
Site Visits are generally unannounced, but there are some organizations that do have announced Site Visits. See below for information specific to your service area.
Organizations that participate in unannounced Site Visits:
- Home health and hospice organizations seeking accreditation with deemed status for Medicare certification
- Home medical equipment providers
- Any multi-service organization that has a deemed service
Organizations that participate in announced Site Visits:
- Organizations for which the above does not apply. In this situation, a CHAP scheduler will contact you to coordinate the Site Visit.
In general, we will be looking for the following information and documents:
- Policy and procedure manual
- Sample admission packet
- List of unduplicated admissions (new patients) for the past 12 months
- List of personnel from the past 12 months
- List of governing body membership
- Mission statement
- Meeting minutes
- Most recent strategic plan
- Most recent annual evaluation conducted for the organization
- List of contracts
- Operating budget
- Capital expenditure plan
- Insurance coverage
- Most recent annual external review of financial statement
- To download the checklist of documents that will be required by your site visitor click: CHAP Requested Documents Checklist
Once you are licensed (if a license is required to provide services in your state), you will need to complete the appropriate forms from the Centers for Medicare and Medicaid Services. These forms will depend on your provider type.
Also, when you apply for accreditation with CHAP, be sure to indicate that you are applying for accreditation with deemed status. If you already have a Medicare provider number, please report it.