How Does a Personnel Change Effect your Accreditation?

We understand that things can often change with your staff, whether it be someone retiring or changing jobs, but it is very important to keep ABC informed of changes with any key personnel within your facility. Not doing so could lead to revocation.

Because Accreditation Standards HR.4.1 and HR.4.2 require that you have the appropriate personnel on staff to serve your patients, your facility must notify ABC in writing of any staff changes that could affect your accreditation within 30 days of the individual’s last day of employment. We encourage you to submit your change of personnel notification via email to accreditation@abcop.org.

Include the following information for the exiting employee:

  • Name of the individual 
  • Last date of employment

Once your notice is received, ABC will review it along with your facility’s record. In most cases, if you are found to be in good standing, ABC will grant your facility a six-month grace period that begins on the last day of the staff member’s employment. During this period, your facility can still operate within the ABC Scope of Practice as well as any state and federal requirements, thus allowing you to complete any billing/claims submissions for services that were provided prior to the individual’s departure. You are allowed ONE personnel change grace period per three-year accreditation cycle. The main purpose of this grace period is to avoid abrupt stops to billing and is not justification for unqualified individuals to provide services.

Whether you decide to hire a new employee or contract someone with the appropriate credentials (within the six-month period), you must also send written notification detailing the following information for the new hire/contractor:

  • Name of the individual at the facility who will be covering that scope of practice (unless you choose to discontinue this service)
  • New hire or replacement staff member’s start date
  • Copy of individual’s state license and/or non-ABC board certification (when applicable)
  • Individual’s work schedule

You are required to send written notification to ABC of a personnel change that affects your accreditation regardless of whether you have hired a replacement or not. Of course, this staff member must be able to provide care within their scope of practice.

If you are unable to hire or contract an individual with the required credential or license after the six-month deadline or you fail to provide a response to ABC, the accredited program related to that individual will be revoked. If you decide to discontinue the services provided by the individual no longer employed by your facility, you must still notify ABC of this change. For more information about personnel changes, please refer to the Maintaining Your Accreditation section of the Guide, pgs. 20-22.

Again, we encourage you to notify ABC of any personnel changes via email as this is the most efficient way for ABC to provide timely feedback and receive any necessary support documentation. As always, you should redact any private information from written correspondence with ABC, especially social security numbers.

Please feel free to email or call us at 703-836-7114 if you have any questions or concerns. We are here to help!