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  • CHAP Accreditation Process Definitions
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• Accreditation Policies and Procedures

CHAP Accreditation Process Definitions

Business and Regulatory Requirements:

The applicant organization must meet all business and regulatory requirements for the services for which they are applying for accreditation, meeting all City, County and State regulations.  This legal entity must have applied for and received all required licenses BEFORE CHAP can process an application for accreditation. 

Programs and Services:

CHAP accredits the following programs and services:

• Home Health (deemed and non-deemed)
• Hospice (deemed and non-deemed)
• Home Medical Equipment
• Pharmacy
• Private Duty
• Infusion Therapy Nursing
• Public Health
• Community Nursing Centers
• Supplemental Staffing Services

CARES Self Study:

A Self Study is completed prior to the Initial Site Visit and then every three (3) years after the renewal of the contract. CARES (Computer-based Accreditation Review System) is an innovative, web-based, custom software application that creates a higher quality, more efficient way to communicate and process vital information.  The applicant is required to complete the Self Study online and provide all required documentation electronically via the CHAP CARES Self Study Portal.

In preparation for the Site Visit, the Self Study provides the Applicant with the tools to conduct a dynamic assessment of their organization in reviewing each standard within CORE and the Service Specific Standards.  As a result, the Applicant will identify and develop a “Project Plan” to address the implementation and consistent application of policies, procedures, practices, and protocols to demonstrate compliance with the CHAP Standards of Excellence.  

The CHAP Standards are written in a “descriptive” format and are adaptable to the size, scope and complexity of any organization.

Completing the Self Study:

CHAP is available to review or discuss any standard or application of the standard within your organization throughout the Self Study process.

Because CARES is operational 24/7 and web-based, your login and password allow you to access the Self Study Portal whenever it is most convenient and from any computer with Internet access.  CARES is eco-friendly too, dramatically reducing paper usage, which is important for everyone.

Site Visit Readiness:

In addition to submission of the Self Study, organizations seeking initial CHAP accreditation may have other requirements to meet in order to be scheduled for their site visit.  These requirements vary by service line seeking accreditation and whether the organization is also requesting Medicare Deemed Status. (With Deemed Status, CHAP performs the Medicare certification survey instead of the state agency, and monitors the agency performance in accordance with CMS guidelines.)

This table summarizes readiness requirements for initial accreditation for all service lines. Organizations need to notify CHAP in writing of the number of patients they have served to meet the census readiness requirements. There is no minimum census requirement for organizations who already have a valid CCN (Medicare Provider Number).

Service Line	Documents	Add’l if Deemed Status	Census Requirements
Home Health	Completed self study (electronic) Copy of state license(s), if required by state	Copy of approved 855A letter Copy of OASIS test transmission	Served 10 7 active at time of survey
Hospice	Completed self study (electronic) Copy of state license(s), if required by state	Copy of approved 855A letter	Served 5 3 active at time of survey
Home Medical Equipment	Completed self study (electronic) Copy of state license(s), if required by state	Copy of approved 855S letter	Served 5 (sale or rental) No active patients required at time of survey
Pharmacy	Completed self study (electronic) Copy of state license(s), if required by state		Served 5 (sale or rental) No active patients required at time of survey
Private Duty	Completed self study (electronic) Copy of state license(s), if required by state		Served 8 4 active at time of survey
Infusion Nursing	Completed self study (electronic) Copy of state license(s), if required by state		Served 5 3 active at time of survey
Public Health	Completed self study (electronic)		Served 5 No active patients required at time of survey
Community Nursing Center	Completed self study (electronic)		Served 5 No active patients required at time of survey
Supplemental Staffing	Completed self study (electronic) Copy of state license(s), if required by state		Served 5 No active patients required at time of survey

Site Visit Scheduling:

Site visits are assigned a site visitor(s) and scheduled based on confirmation of all applicable pre-site visit requirements being met and for Initial and Renewal Accreditation, in order of submission of completed Self Studies.  Organizations are encouraged to communicate “black out” dates when key personnel absences or key organizational activities make an accreditation site visit difficult. CHAP will accommodate these requests as much as possible, but site visits can rarely go beyond 36 months since the previous visit without incurring risk of termination of accreditation.  These instances must be approved in a written extension of accreditation from CHAP.

Please communicate requested black-out dates via email to scheduling@chapinc.org.

For Initial Accreditation:

Required number of active patients and total number of patients served varies by Service seeking accreditation.

Site visits will be scheduled as either:

1) Unannounced

• Home Health and Hospice organizations seeking deemed status Medicare Certification in addition to CHAP Accreditation
• Home Medical Equipment (HME/DMEPOS)
• Pharmacy
• For any multi-service organization with a deemed service, the site visit will be unannounced.

OR

2) Announced

• For organizations for which the above does not apply, CHAP scheduler will contact the Applicant to coordinate the Site Visit. 

For Renewal Accreditation:

A comprehensive site visit will be conducted at the beginning of each accreditation cycle, following the renewal application, Accreditation Services Agreement, and self study, at a 30-36 month interval since the most recent comprehensive site visit.

Site Visitor Credentials:

Site visitors are required to have a minimum of 5 years experience in a health care field that reflects the scope of care and services accredited by CHAP.

• Minimum of a Bachelor's degree in a related specialty area; preferred education at the Master's level.

• Minimum of 5 years management/executive level experience in a community-based health care organization.

• Site visitors are assigned to perform accreditation visits only for services where they have specific experience.

Board of Review:

• The CHAP Board of Review (BOR) is comprised of community health professionals appointed by the CHAP Board of Directors.  These individuals are representative of CHAP accredited organizations which have completed at least two Comprehensive Site Visits (three year cycles) and have minimal or no Required Actions.  The organizations that they represent exemplify and demonstrate consistent compliance with the CHAP standards
• All site visits are reviewed with all identifying information removed, to preserve the objectivity of the review. In addition, Board of Review members follow CHAP’s conflict of interest/disclosure policies.

Document Requirements:

Community Health Accreditation Program: Document Request

NOTE:  This is a Guideline.  Additional information may be requested based on scope and complexity of service (s) provided by the organization.

What to Expect After the Site Visit:

CONGRATULATIONS!  You have now completed another important phase of the accreditation process!

Final accreditation is the goal, and here is what will come next on the journey to that outcome:

Process	Who?	When?
Verbal findings and recommendation re: accreditation	CHAP-Site Visitor	Exit Conference last day of site visit
Finalize and email report/POC	CHAP-Administrative Staff	10 business days after Exit Conference
Develop and document POC	Organization	10 calendar days after receipt of POC
Accept/reject POC	CHAP-Administrative Staff	10 days after receipt of POC
Report to BOR	CHAP-Administrative Staff	Month following site visit
Final accreditation determination to org.	CHAP-Administrative Staff	Month following BOR

Please be aware that CMS randomly selects a small percentage of the surveys that CHAP performs for organizations seeking accreditation with deemed status for a validation survey.  If your organization is selected, the validation visit will be unannounced, and will occur within 60 days of the CHAP visit.  You need to notify CHAP if you experience a validation visit, and also copy CHAP on any Statement of Deficiencies/Plan of Correction or other correspondence related to the validation visit.

CHAP Media Kit for Accredited Agencies:

The CHAP Media Kit provides basic information on how CHAP accredited agencies can commemorate and publicize CHAP accreditation with staff, customers, and their community.

Included in this kit are some simple ideas to help you celebrate CHAP accreditation, publicize this great accomplishment with press releases and on Websites, and leverage the distinction of being CHAP accredited in advertising and promotional materials.

Also included are technical guidelines for using the CHAP certificate and CHAP Seal artwork.