Patient Care Facility Accreditation Guide

The Basics

All applicants must meet the applicable eligibility criteria and demonstrate full compliance with the Standards outlined in this Guide before accreditation can be granted.

Compliance is determined by a review of your application materials, an onsite survey, and a final validation of your surveyor’s findings. The onsite survey is conducted by professionally trained and qualified surveyors.

As required by CMS, all surveys for patient care accreditation are unannounced and unscheduled and occur during your posted business hours.

By submitting your application, you declare that you are ready for an onsite survey at any time. Surveys will not be rescheduled due to emergency closure, staff unavailability, or lack of readiness.

If access to the facility or required documentation is denied, or if the facility is closed during the hours of operation sub, the facility will automatically fail the survey. To be resurveyed, the facility must submit a new application, including all applicable fees and required documentation.

Types of Surveys

Initial Survey (First-Time Applicants)

Initial surveys are for newly operating facilities, established facilities that have not been previously accredited, ownership changes, and facilities switching from another accrediting organization. Facilities considering accreditation are encouraged to review the Guide and complete the Pre-Application Checklist. To be placed in the queue for an initial survey, submit a request to create an account/login and then submit a completed online application.

Reaccreditation Survey

Reaccreditation surveys are utilized for sites with existing ABC accreditation. These surveys also cover physical address changes or additions to accreditation program. We send renewal reminders to the primary email address and mail them to the facility. Reaccreditation applications are due by January 15 of the expiration year. Late applications or holds may prevent completion of  the onsite survey before expiration. Reaccreditation surveys also review prior deficiencies and corrections. 

Verification Survey

ABC reserves the right to randomly visit accredited facilities to conduct verification surveys to assess compliance within a facility or for quality control purposes.  ABC will notify the facility if a verification survey is required, and the facility is responsible for associated fees.

CMS-Directed Surveys

As a CMS-deemed accrediting organization, ABC may be required by CMS to conduct additional surveys outside of the facility’s regular reaccreditation cycle. Such surveys are conducted on an unannounced basis, and the facility is responsible for all applicable fees.

Surveyors

Once your facility’s survey has selected by a surveyor, you will receive an email with your surveyor’s name. All ABC surveyors must disclose any potential conflict of interest with the facility to us before they are assigned to conduct the survey. If you have a conflict of interest with your assigned surveyor, please email accreditation@ABCop.org with your name, facility’s contact information, and reason within five days of receiving your assigned surveyor email. Requests made after the five days may be denied. The following constitute as valid conflict of interest:

Once a surveyor has been assigned to your facily's survey, you will receive an email with your surveyor’s name. All ABC surveyors/apprentices must disclose any potential conflict of interest with the applicant/facility to us before they are assigned to conduct the survey. If you have a conflict of interest with your assigned surveyor, please email accreditation@ ABCop.org with your name, facility’s contact information, and reason within five days of receiving your assigned surveyor email. Requests made after the five days will be denied. The following constitute a valid conflict of interest:

• The surveyor has provided consulting services, accreditation guidance or other advisory services to the facility.
• The surveyor has a personal relationship with an owner, shareholder, employee or other individual affiliated with the facility.
• A conflict of interest may arise if the surveyor accepts employment with or enters into a contractual relationship with the facility.
• A surveyor may be considered to have a conflict of interest if they are currently, or were previously, employed by or contracted with a competing business located in the facility’s local area.
• ABC will not assign a surveyor to a facility when a conflict of interest has been identified and confirmed.

Following the onsite survey, all questions and communications must be directed to ABC staff. Surveyors are not available for follow-up consultation, and their personal contact information will not be provided. For assistance throughout the accreditation process, please email accreditation@ABCop.org.

About Our Surveyors:

Background

Our surveyors come from a variety of backgrounds, giving them unique perspectives as they conduct your survey. ABC selects surveyors for their extensive experience, compliance knowledge, and commitment to ABC and our mission. They demonstrate objectivity, diplomacy, and dedication to our profession.

Site Surveyor Training

Each surveyor completes formal, structured training through seminars, meetings, and ongoing education, including updates on electronic medical record (EMR) systems. In addition, surveyors are provided with materials and tools specifically designed to support the survey process and reinforce their understanding and consistent application of the ABC Accreditation Standards.

Approach

ABC surveyors demonstrate maturity, objectivity, diplomacy, and dedication. They project professionalism in both behavior and appearance. In addition, our surveyors appreciate the confidential nature of the task and understand the need for self-initiative, a cooperative attitude, an analytical approach, and the necessary flexibility.