Mastectomy Facility Accreditation Guide

October 2023


Human Resources (HR)

The Human Resource Standards apply to all staff at the business’ physical location, whether directly employed, contracted or serving in a volunteer capacity, providing patient care services or supporting activities. The terms staff and staff member (and their derivatives) as used in these Standards are intended to refer to all of your care providers and support staff. The business ownership/leadership is responsible for hiring and privileging its staff and ensuring that your staff has the necessary skills to perform their job.


You must annually document that you have verified current licenses and certifications held by all staff members who provide patient services.


You must verify the certifications and licenses (if applicable) of all of your fitters annually. You can contact your credentialing agency (licensure or certification board) and request verification that the individual’s credentials are still valid via phone, email or check the agency’s website directory. Once you have verified the credential/ license, document the date and the method that you used in the employee’s personnel file or another file that you have specifically for this purpose. Use the Annual Employee Verification form in the online Resource Pack to accomplish this verification.


In the absence of state licensure requirements, staff providing custom fitted prefabricated or custom fabricated items and services shall be certified as appropriate and function within the ABC Mastectomy Scope of Practice.


Your patient records and office policies must demonstrate that personnel providing these services are certified. You must provide copies of their current certifications. Your patient care records must indicate by notes and signatures that care is being provided by the appropriate certified staff.


You may privilege non-credentialed or non-licensed staff to provide patient care under the supervision of a credentialed or licensed individual practicing within their scope of practice. If you privilege a staff member, your process must be in compliance with applicable laws, based on Written Objective Criteria* and under the Indirect Supervision* of a credentialed or licensed individual practicing within their scope of practice. You may privilege credentialed staff to provide patient care beyond their ABC Mastectomy Scope of Practice.


Non-credentialed or non-licensed employees can be privileged to provide devices, items or services. However, you must document that you have established Written Objective Criteria to assess the competency of each person. This requirement also includes credentialed staff privileged to provide items and services beyond their scope of practice. Your documentation could be one of many different forms, including but not limited to, proof of completion of continuing education courses related to particular items, documented in-house or in-service training that is specific to the items or services that the patient care provider is being privileged to provide and/ or documented specific work experience participating in patient care activities. You will need written documentation for each privileged patient care provider describing what criteria they met and how they met it. The supervisor’s co-signature must appear in all patient charts. Use the Instructions for Using Privileging Criteria and the Individual Privileging Criteria form in the online Resource Pack to help you with the documentation.

* See definition of Written Objective Criteria and Indirect Supervision in the ABC Mastectomy Scope of Practice.