Patient Care Facility Accreditation Guide

Our goal is to make the accreditation process as effective and uncomplicated as possible. The following information will help you understand what you can expect from the process.

Preparing for your Survey

Before applying, make sure your facility is compliant with the eligibility criteria and the Standards. We offer a variety of accreditation tools on our website, ABCop.org. The Custom Standards tool is one important tool that will assist you in determining which Standards apply to the product categories you are providing. Accredited facilities also have access to our online Compliance Kit Resource Pack. Additional preparation resources can be found in the Resources & Links section of this Guide or on our website.

Survey Structure

PRIOR TO YOUR SURVEY

Supporting documentation, including your Policies and Procedures and Employee Manuals, should be uploaded to the application portal before the onsite survey. Providing these documents in advance allows the surveyor to review necessary information and make more effective use of their time onsite. During the survey, the surveyor may also request to review these documents at the facility and verify that staff have appropriate access to applicable policies and procedures.

Initial Interview

Your surveyor(s) will conduct an initial meeting with your facility’s survey contact or designated representative. At this time, the lead surveyor will:

• Briefly introduce themselves, along with other members of the survey team (if applicable).
• Discuss the survey objectives and the day’s schedule.
• Answer any questions you may have regarding the survey.
• Ask you to describe the general layout of the facility, conduct a tour of the facility, and provide any additional details about the facility, its operations, or staff that should be noted as part of the survey.

Information Gathering

To verify that you have met the requirements of ABC’s Accreditation Standards, your surveyor will review many areas, including:

• Personnel files
• Patient records
• Accounting and bookkeeping records
• Contracts with vendors, staff members
• Agreements with physician’s offices
• Fire safety and emergency management plans and documentation
• Patient satisfaction surveys and results
• Product delivery information

By applying for accreditation, you authorize ABC and our surveyors access to all records (including patient, personnel, financial management, risk management, operational review, quality assurance and quality improvement) and physical areas necessary to determine your facility’s compliance with the ABC Standards.

Your surveyor will also conduct staff and patient interviews and may look at other areas as they relate to the Standards. All Protected Health Information (PHI) is treated in accordance with Health Insurance Portability and Accountability Act (HIPAA) regulations.

Per CMS, surveyors are required to call a sample of Medicare patients and ask whether they received information about device function, care and use; benefits and precautions; follow-up; contact information for problems; and whether they have questions about the device or services received. We recommend that a staff member be present in case your patient has any questions.

Closing Interview

Surveyors discuss general findings and provide a final opportunity to clarify information or present documentation. Significant recommendations and deficiencies are discussed. However, surveyors cannot say whether your facility has passed.

After the Survey—Results

Scoring Process

Surveyors submit their initial findings to ABC. Staff then validate and finalize the results. ABC emails finalized results within 1–3 weeks, and mails a hard copy within 6–8 weeks. Staff do not process reaccreditation results if invoices remain outstanding.

Accreditation Decision

The decision email provides access to the decision letter, survey report, and certificate, if applicable. Standards may be marked Compliant or Non-Compliant. Standards marked  Non-Compliant will include the surveyor’s comments to assist with corrective action.