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Home > Facility Accreditation > Patient Care > FAQs

FAQs

 Applying for Accreditation
​​Can I provide services prior to being accredited?
Yes, ABC requires that you are operational at the time of survey and requires a minimum of 10 patient charts from your facility. However, you may or may not be able to bill third party payers. Please check with the payers that you work with to see if you are required to be accredited prior to providing payer covered services.

Can I apply without having board certified or licensed staff members?
It is your facility's responsibility to have appropriately certified and/or licensed staff members at the time of your facility's application. Please do not submit an application if you do not have a certified and/or licensed professional on staff.

Do I need to apply for all scopes of service that I am providing or just specific ones?
You must apply for ABC accreditation for all of the services you provide regardless of whether your facility is billing CMS for those services. This requirement extends only to those services for which ABC offers accreditation.

How long will my accreditation be effective?
Most accreditations are valid for up to three years.

What if our facility is moving?
If you plan on moving your facility during the accreditation process and you have already submitted your application, we recommend placing your application on hold.

If you have not submitted an application, consider moving to your new location before applying.

If your site is currently ABC accredited, submit a renewal application with a detailed cover letter regarding the changes and appropriate application fees. Accreditation is non-transferrable.

What if I have contracts that are pending accreditation?
Please submit a statement with your application detailing any pending contracts. We do our best to accommodate all requests, but this is not always possible.

How can I obtain additional copies of my accreditation certificate?

Reprints of certificates are $25 per item. You can order reprints directly from the ABC website by clicking on the My ABC button above and logging into your facility's account. 

 Accreditation Survey
​Can I schedule my survey?
No. CMS requires that all surveys be unannounced.

What if I'm not ready for the survey?
Please do not submit your application until you are ready for your onsite survey.
If you have already submitted your application and believe you are not ready for your onsite review, we recommend placing your application on hold until you are comfortable with the preparedness of your facility. Please be advised that placing your application on hold takes you out of the survey process and resets your application date to the date you come back into active status.

You must request on hold status in writing at least 30 business days in advance. When your site is available to be surveyed again, you must also notify ABC in writing. Your application can be placed on hold for a maximum of six months, starting from the date you notify ABC. If we do not hear from you in writing by the deadline, you will need to resubmit an application and appropriate fees.

Do surveyors show up on holidays?
No, surveyors will not conduct surveys on major holidays or holiday observation days.

What if I have plans to be out of the office?
If you plan on being out of the office, you may request blackout dates when you submit your application. All other requests for blackout dates must be in writing at least 30 business days in advance. Black-out periods are for a maximum of two consecutive weeks. If you need a longer black-out period, you must put your application on hold. Hold requests must be made in writing at least 30 days in advance. Please note that ABC will attempt to honor these types of requests but this is not always possible.

You can mail or fax your request to:

ABC
Attn: Facility Accreditation
330 John Carlyle St, Ste​ 210
Alexandria, VA 22314

​Fax: (703) 842-8027

What if I have an emergency and need to step out of the office during my regular business hours?
ABC recommends that you have contingency plans for all emergencies. In fact, you should always have a backup person who knows the location all of the information the surveyor will need. However, if that is not possible, you should place a visible note outside your door with the contact information (name, cell phone number) and return time so that if the surveyor arrives during your absence, they can contact someone to return to the facility.

Does the facility owner need to be present during the survey?
No. As long as someone can allow the surveyor on site, answer questions and access paperwork, the owner is not required to be present.

What is a Quality Control Survey?
A quality control survey is a survey performed by ABC used to identify trends within the accreditation program. The purpose of this survey is to ensure accuracy and that quality data is being collected.​​

 Privileging

What is privileging?
Privileging refers to giving an individual permission or ‘privileges’ to engage in specified clinical activities. ABC defines how a credentialed person may be allowed, under supervision, to provide items and services outside of their scope of practice. That privileging process is described in detail in the ABC Orthotic, Prosthetic and Pedorthic Scope of Practice. 

Why is the ability to privilege a non-certified individual being eliminated?
The ABC board of directors feels strongly that the education and training required for certification are critical elements in the provision of safe and effective patient care. We believe this change raises the standard of care and upholds the highest level of patient care services by ABC credential holders.

When does the change take effect?
The change to privileging will take effect January 1, 2019. After that date ABC accredited facilities and certified individuals will no longer be able to privilege a non-credentialed person to provide patient care services.

Are non-certified individuals allowed to provide any services?
Certain patient care tasks can be delegated to non-credentialed individuals. The new definition for Support Personnel details what aspects of patient care can be delegated to non-credentialed persons. For more information, refer to the definition of Support Personnel​. This definition goes into effect on January 1, 2019.

What are my options if I currently privilege non-certified individuals?
After January 1, 2019 you will not be able to privilege a non-credentialed person to provide custom fitted or custom fabricated services. You should consider encouraging your non-credentialed staff to become certified as an orthotic or prosthetic assistant, an orthotic fitter or a therapeutic shoe fitter depending on what your practice needs. Non-credentialed individuals will continue to be allowed to provide off-the-shelf items after January 1, 2019.

How will this affect my accreditation?
After January 1, 2019 all ABC accredited facilities will have to comply with the new standards. There will be no impact to your accreditation until that date. You should begin now to review your practice’s policies and procedures if you currently privilege non-credentialed individuals to provide patient care.

Does this change affect the accreditation standards?
Standards HR.6 and HR.6.1 will be revised to reflect the changes to the privileging rules. The revised standards will be published in 2018 prior to their ​taking effect in January 2019.

How can I modify my current policies to meet the new standards?
If you don’t currently privilege non-credentialed staff to provide patient care services you do not need to make any changes to your practice. If you are currently privileging non-credentialed staff, you need to assess what types of items/services the non-credentialed individuals are providing. If they are only providing off-the-shelf items, they can continue to provide these types of items. If they are providing any services related to custom fitted or custom fabricated items, this change will impact that ability. In order to continue to provide those services, your non-credentialed individuals will need to become certified as an orthotic or prosthetic assistant, an orthotic fitter or a therapeutic shoe fitter. You should also review the new definition of Support Personnel to determine if your practice’s needs can be met within the framework of that definition.

Will current non-certified care providers be grandfathered in so that they can continue to be privileged to provide care? 
No, there will be no grandfathering. All ABC accredited facilities and certified individuals will have to comply with the changes to the Scope of Practice beginning January 1, 2019.

My non-certified individual is providing OTS; do they need to be privileged?
No. Off-the-shelf items can be provided by any staff member; no certification is required. Any item that has ‘off-the-shelf’ in the Medicare HCPCS L-code descriptor is considered an off-the-shelf item. This does not include diabetic HCPCS codes (e.g., A5500).​

 Corrective Action Plan (CAP)
​​What is a Corrective Action Plan?
A Corrective Action Plan (CAP) is a document submitted to ABC that demonstrates your facility’s
compliance with one or more standards that were in question after your onsite survey.

When is a CAP required?
ABC may request a CAP for any of the following reasons:
• Your facility receives an overall failing score
• Your facility passes overall but falls below the passing threshold for a full three-year accreditation
• Your facility missed any standards that are considered mandatory, regardless of overall score. These standards are:
​​AD.5, AD.6 ​           ​​ HR.6, HR.6.1    ​ PC.6.9, PC.6.9.1   ​ FS.3.2.2, CB.1
​​​HR.4.1, HR.4.2   ​ HR.8.2, HR.8.3​PC.9.1, PM.10​CB.4.1
               
If you receive a request from ABC for a CAP, your accreditation is not fi nal until your CAP has been approved.
If you fail to submit a CAP by the deadline, your application for accreditation will be denied and any existing
accreditation may be revoked. You will then need to submit a new application, including all fees, for an
additional onsite survey.

Is there any cost to submit a CAP?
No. However, if you are required to have an additional onsite survey, you will be notifi ed in your accreditation
decision letter. Resurveys will require additional fees.

What is the proper format for CAPs?
Address each standard marked N (Non-Compliant) or P (Partially Compliant) in the following format:
​
​EXAMPLE:​​​
​
​Standard: 
​FS.3.2.2​
​Description of
corrective action:
​We have now completed a yearly fi re drill. In the
future, these will be completed on the fi rst Monday of
December.
​Documentation:
​A completed copy of the fi re drill report, including
signatures of employees in attendance.

​Can I just submit my entire Policies and Procedures Manual?
No. Only submit the specifi c policies and procedures that are directly relevant to the surveyor’s comments. Policy
and procedure manuals will not be accepted as a CAP.​

What should be included in my CAP?
Include copies of all completed documentation showing that changes have been made. New forms, logs, training notes and annual reports must be fi lled in with the appropriate information. Meeting minutes and notes with patient-identifying information removed can also be used to support correction statements. If applicable, completed documentation should include dates, signatures and information about when the next audit/check will be performed.

Note: If a completed annual review for your facility is part of the documentation needed for your CAP, ABC asks that you go ahead and perform the review with the information you have available, even if the scheduled date for that review is after your CAP deadline. This will help ABC better evaluate your accreditation status.

DO NOT send original documents, as items submitted to ABC will not be returned.

What if my CAP is incomplete?
If ABC needs more information to make a fi nal decision, you will have one more opportunity to submit materials. You will receive a second request letter with a new deadline and details about what information is still needed.

Once complete, how do I submit my CAP?
You may mail, fax or email your CAP to:
ABC
Attn: Standards and Compliance Assistant
330 John Carlyle St, Suite 210
Alexandria, VA 22314
Fax: (703) 836-0838
Email: apotter@abcop.org​

How will I know that you have received my CAP?
Upon receipt of your CAP, we will send you an email confi rmation. We suggest that you follow up with us if you have not received a confi rmation within one week of sending in your CAP.

What is the timeline for CAP submission and review?
• Within 60 days of the date of your decision letter, you must make the required corrections for your facility
and submit your CAP.

• Within 60 days of receiving your completed CAP, we will review your submission. Due to the intensive
nature and volume of CAP reviews, it takes approximately eight weeks for this process.

• If your CAP is incomplete or requires additional information, you may receive a second CAP request. At
that time, the above timeline will start over.

​CAP Submission Checklist
__ All standards marked P or N are addressed
__ Documentation is included for all standards
__ Patient names, birth dates, social security numbers, etc. are blacked out
__ All template forms and logs are completed
__ Where policies have been revised or implemented, a copy of the single policy is included
__ Facility has retained all originals and sent only copies to ABC
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