Patient Care Facility Accreditation Guide

Full Approval

ABC Facility Accreditation is awarded when there is full compliance with all applicable standards. Facilities with full approval will receive an electronic decision, survey report, and certificate, with copies mailed to the primary facility.

Corrective Action Plan (CAP) Decisions

If a facility has any deficiency, the facility may be given the opportunity to submit a Corrective Action Plan (CAP). A CAP demonstrates compliance with the standard(s) in question. CAPs are reviewed on a case-by-case basis, and submission does not guarantee accreditation.

Failure to submit an approved CAP within the allotted time results in revocation of existing accreditation or denial of accreditation. No fees are associated with CAP submission.

Fail with a Corrective Action Plan Requirement

If the overall score is not within the passing range, the facility may be given the opportunity to submit a CAP. During the review period, your facility is not considered accredited.

Corrective Action Plan Timeline

CAPS are due within 14 days of the decision email date -failure to submit a CAP by the deadline results in denial or revocation. CAPs will be reviewed by our Standards and Compliance team. Once the review is complete, a decision will be communicated via email.

Incomplete Corrective Action Plans

If a CAP does not adequately demonstrate compliance with the applicable standards, ABC may request additional information or documentation within a specified timeframe or require a resurvey of the facility 

Supporting Corrective Action Documentation and Format

A CAP must include supporting evidence that shows how changes have been implemented to address each missed (P or N) standard. This can include completed forms, logs, training notes, annual reports, de-identified patient notes, pertinent updated policies, and meeting minutes. Entire Policy and Procedure manuals are not accepted as a CAP unless directly relevant to the surveyor's comment or standard.

Denial/Revocation

Common reasons for accreditation denial or revocation include, but are not limited to, the facility being closed at the time of an attempted survey during the hours of operation submitted to ABC, facility staff refusing or declining to allow the survey to proceed, or survey findings that demonstrate noncompliance with applicable standards.

If accreditation is denied, the facility must submit a new application and applicable fees to reapply. If an accredited facility’s accreditation is revoked, the revocation will be effective as of the date of the survey, and the facility must submit a new application and applicable fees to pursue accreditation again.

Accreditation Effective Dates

For new and reaccrediting facilities, effective dates may be the first day following a passing initial survey, the date a reaccreditation application was received when the reaccreditation survey is passed, or the date a qualifying CAP was received.  Accreditation for facilities requesting add-on services may be effective on the application receipt date if the add-on survey is passed.