CHAP’s seven-step process will get you to the accreditation finish line.

 

CHAP’s Accreditation Process 

CHAP’s accreditation process is easy and straightforward. Get started immediately with our online tools that remove the guesswork and minimize disruption to your business.

When you get to know and apply our Standards of Excellence, you’ll find you can deliver a better quality of care and run a better business overall. Should you need help along the way, our customer service representatives are available.

Complete and submit your application.

Requirements

Your responsibility

  • Create your account at CHAPLinQ
  • Complete application and upload applicable license
  • Submit application
  • Pay $800 non-refundable application fee

CHAP’s responsibility

  • Review application
  • Confirm all information is complete and verify required documents
  • Determine fees and Site Visit days based on locations, clients and services
  • Provide 3-year accreditation services agreement

Estimated time

  • 3-5 business days from submitted application to contract

The contract includes detailed policies and procedures, and spells out duties and responsibilities for both you and CHAP. The contract is for a 3-year period.

Requirements

  • Accepted application

Your responsibility

  • Sign and return contract
  • Pay first installment of the accreditation fees by check or by credit card

CHAP’s responsibility

  • Execute contract upon receipt of signature and payment

Estimated time

  • 2-3 business days from executed contract

Considerations

  • Once the contract is executed, applicant is responsible for the full accreditation fees for the term of the contract.

The CHAP Self Study helps you complete a comprehensive internal evaluation of the business and service aspects of your organization.

First, you’ll get to know and understand our Standards of Excellence; then you’ll assess how your organization is doing compared to them. Are you meeting the standards, or do you need to make changes?

An added bonus: Many organizations use the Self Study as the foundation for a business plan to ensure compliance with all of the standards. 

Requirements

  • Executed contract

Your responsibility

  • Self Study
    • Complete Self Study to conduct comprehensive internal evaluation of both business and service aspects of your organization

Readiness

  • Upon completion of the Self Study, communicate Site Visit readiness in CHAP LinQ
  • Include any changes in the number of active clients
  • You may request up to 15 “blackout days” per accreditation cycle. CHAP will avoid scheduling your visit on these days.

CHAP’s responsibility

  • Schedule visit
  • Assigned site visitor will review Self Study prior to visit

Estimated time

  • 3 months to complete self study

Considerations

  • A request may be made in CHAP LinQ to extend the due date for Self Study — CHAP has sole discretion to grant an extension for good cause for a period not to exceed 90 days

CHAP evaluates your company’s evidence of compliance with our Standards of Excellence, working with you as an educator and coach.

The Site Visit begins with a conference where the Site Visitors introduce themselves and develop a plan for the visit. They will request a variety of documents, including personnel files, consumer/clinical records, policy and procedure manuals, and meeting minutes. Over a few days, they will observe the workplace and care provision, as well as interview management and staff. They will also make home visits to observe services being rendered and to interview clients.

Requirements

  • Before a Site Visit can be scheduled, readiness must be submitted in CHAP LinQ.

Your responsibility

  • Provide space for the Site Visitor to conduct work, plus documents, files and patient staff lists as requested
  • Allow observation and interview of staff, patients and agency leadership in different settings as appropriate
  • Sign “pre-bill” at end of visit

CHAP’s responsibility

  • Site Visitor (or lead Site Visitor if more than one) will conduct entrance and exit conferences, along with daily check-ins
  • Site Visitor provides a preliminary report of any performance deficiencies and a “pre-bill” form that indicates the number of Site Visit days to be invoiced (e.g., two Site Visitors at the agency for 3 days = 6 total Site Visitor days)

Estimated time

  • 1 to 90 days from readiness to Site Visit

Considerations

  • If the Site Visitor is refused entry, the visit is recorded as aborted and the applicant is charged the aborted-visit fee.
  • If the applicant is not present to conduct the survey, or failed to notify CHAP in advance that it does not meet census requirements, the applicant is charged the cancellation fee.
  • If a site visit, of any type, is aborted by a CHAP-accredited agency, the applicant is charged an aborted-visit fee and the termination process is initiated

If there are any performance deficiencies found during the Site Visit, you will be required to complete a Plan of Correction (POC) to continue your accreditation process.

Requirements

  • Completed Site Visit
  • Only applies if required actions were identified during the Site Visit

Your responsibility

  • Submit a POC
  • The POC is due within 10 calendar days of notification from CHAP Director of Accreditation
  • If the Director of Accreditation asks for revisions, the applicant must submit modified POC within 5 calendar days

CHAP’s responsibility

  • Director of Accreditation will notify the organization of POC requirement within 10 business days from the last day of the Site Visit
  • Director of Accreditation either accepts or requests further modifications to the POC within 10 business days
  • CHAP will respond to a revised POC within 10 business days of receipt of the submitted POC
  • Ultimately, an acceptable POC will be agreed upon for submission to CHAP Board of Review

Considerations

  • An organization can submit an appeal of specific findings directly to the Director of Accreditation at this time

Estimated time

  • 30 days from last day of Site Visit

Once the Plan of Correction (POC) is accepted, the Board of Review will assess all of your materials to date (with all of your organization’s identifying information removed).

Requirements

  • Completed Site Visit with no required actions or accepted POC

Your Responsibility

The Board of Review (BOR) will review the POC (names and identifiers removed) and make one of the following accreditation determinations:

  • Accreditation
  • Accreditation with required action (POC)
  • Accreditation with required action (POC) and follow-up visit within a specified time frame
  • Deferred/denied accreditation - organizations with serious deficiencies
  • Formal warning - renewing organizations, requires a POC and follow-up  visit
  • Termination of accreditation - renewing organizations with serious deficiencies they are unable to clear

CHAP's Responsibility

  • Applicant is notified via e-mail of the determination
  • Termination determinations will be sent via certified mail 

Considerations

  • An organization may appeal a BOR determination within 10 business days of notification of decision. If applicant remains dissatisfied, a final appeal can be made within 30 days to the CHAP Board of Directors, whose decision is final

Estimated time

  • 21 days from accepted POC

Your organization receives full CHAP accreditation!

Your responsibility

  • Celebrate your success and continue to pursue ongoing adherence to Standards of Excellence

CHAP’s responsibility

  • Send formal letter and certificate of accreditation via U.S. mail
  • List on CHAP website
  • Access to CHAP Media Kit for accredited organizations located in CHAPLinQ
  • Accreditation letter and required CMS documentation is sent to CMS.

Considerations

  • The CMS regional office notifies the accredited organization directly regarding Medicare certification
  • The CHAP accreditation process is 3 years from the date the final acceptable POC is submitted, or if renewing, from the last day of the previous comprehensive Site Visit

Estimated time (H3)

  • 2-4 weeks from BOR determination to accreditation determination