CHAP keeps customers up-to-date about what happens throughout the accreditation process.

Site Visit Readiness

In the accreditation process, it’s important to be prepared. That’s why CHAP works hard to keep customers informed of what will be happening and when.

The Site Visit is a critical step in the accreditation process, which is why CHAP strives to accommodate an organization’s scheduling needs when planning.  

However, if a CHAP Site Visitor arrives at an organization and the Site Visit cannot be completed due to a refusal to continue, it is considered aborted (terminated without completion). CHAP considers it a serious violation when a Site Visitor arrives at an agency and is prohibited from conducting a Site Visit required by CMS and/or the CHAP Board of Review.

Here’s what you should do to prevent an aborted Site Visit:

  • Read the CHAP accreditation letter very carefully. If a focus visit is required after a Site Visit, you will be notified in the CHAP accreditation letter.
  • Organizations anticipating a focus visit should contact their CHAP accreditation specialist with as much advance notice as possible, preferably within at least 30 days, to request blackout dates (dates when the Site Visit should not occur). Organizations can also request blackout dates through CHAP LinQ.
  • Make sure that you have the appropriate staff available to meet the CHAP Site Visitor to begin the survey. Once the CHAP Site Visitor arrives onsite, they are required to wait an hour for agency staff to arrive and begin.

If an organization received a conditional level finding previously, and have no active patients or additional documentation to review since the last Site Visit, the finding cannot be “cleared.” The original finding will remain.

Agencies applying for initial accreditation must meet census requirements in order to be ready for a Site Visit. If they do not, the Site Visit is aborted.

For all organizations, a fee of $2,200 will be charged for each aborted Site Visit. The figure allows CHAP to cover the travel and expenses for our Site Visitors only, and is not meant to be punitive in nature.

Do you want to confirm that your organization is ready for the Site Visit? Get in touch today and we’ll be sure you have everything you need.

For a checklist of documents that will be required by your site visitor click here

Site Visit Readiness Requirements by Service Line | STEP 03

Service Line

Required Documents

Required Census

Deemed Status Requirements

Home Health

• Completed self study
• Copy of state license(s),
if required by state

• 10 served
• 7 active at time of survey

Copy of approved 855A letter and OASIS test transmission with final validation report

Hospice

• Completed self study
• Copy of state license(s),
if required by state

• 5 served
• 3 active at time of survey

Copy of approved 855A letter

Home Medical Equipment
(HME/DMEPOS)

• Completed self study
• Copy of state license(s),
if required by state

• 5 served (sale or rental)
• No active patients required at time of survey

 

Private Duty

• Completed self study
• Copy of state license(s),
if required by state

• 8 served
• 4 active at time of survey

 

Pharmacy

• Completed self study
• Copy of state license(s),
if required by state

• 5 served (sale or rental)
• No active patients required at time of survey

 

Infusion Therapy Nursing

• Completed self study
• Copy of state license(s),
if required by state

• 5 served
• 3 active at time of survey

 

Public Health

• Completed self study

• 5 served
• No active patients required at time of survey