Step 1. Application

The applicant organization completes and submits the application along with the application fee and any required documents, to CHAP. Upon receipt of the application, CHAP staff will:

• Determine the organization's eligibility for accreditation
• Review the application for completeness
• Estimate the number of site visit days necessary to survey the organization
• Complete and send two original contracts to the applicant organization for signature

When the contracts are signed and returned to the CHAP office, copies of the applicable Standards and Self Studies are forwarded to the applicant organization along with 1 originally executed copy of the contract. The contract spells out the duties and responsibilities of the parties and locks in the agreement and fees for a 3 year term.

Step 2.The Self Studies

The Self Studies are a unique and insightful self-evaluation tool, which addresses both the business and service aspects of the applicant organization. The Self Studies are due in the CHAP office between three to six months of the date of the contract. CHAP staff will review the documents for completeness and begin analysis of the content. Organizations using the CHAP CARES Client Portal will complete their self study online, uploading attachments in interactive online sessions. For more information on CARES click here.

The purpose of the Self Studies are two-fold: they afford the organization the opportunity to complete a comprehensive internal evaluation and review of their operations in preparation for the site visit and the CHAP staff uses the information submitted to plan and execute the site visit. Updated Self Studies are prepared and submitted at the start of each new accreditation cycle.

Step 3. The Site Visit

The number of site visitors assigned to a visit depends on the type of visit, size of organization, and the complexity of services and products provided. If 2 site visitors are assigned, 1 specially trained and experienced site visitor will be designated as the lead site visitor. The lead site visitor is responsible for the following:

• Planning the logistics of the site visit
• Acting as spokesperson for the team
• Coordinating all the activities of the site visit team
• Providing support and direction to the team members
• Ensuring the timely completion of the Site Visit Report
• Providing consultation to the organization

The site visit team is comprised of health care professionals, highly experienced in their respective fields. The focus is to provide professional assistance while ensuring compliance with the CHAP Standards of Excellence and other regulatory requirements. Emphasis is placed on the concepts of operational management, performance improvement planning, adequate levels of resources, consumer satisfaction and outcomes, and the long-term viability of the organization, as well as promoting public recognition of the quality of services and products provided.

The composition of a site visit team is contingent upon the types of programs and services provided. Site visitors are selected based on their professional background and special areas of expertise that are relevant to the planned site visit.

Qualifications of site visitors:

Lead site visitor qualifications require a minimum of 5 year's executive level experience in a community-based health care organization and education at the Master's level (Preferred).

Site visitors are required to have 5 years experience in a health care field that reflects the scope of care and services accredited by CHAP and have a minimum of a Bachelor's degree in a related specialty area.

An evaluation of the site visitors involves a 5 prong process:

• Written evaluation by the organization being accredited, addresses the professionalism and preparedness of the site visitor
• Written peer evaluations by members of the site visit team addresses the professionalism of the site visitor, their willingness to function as part of the team, and recommendations for improvement
• Unannounced periodic on-site evaluation of the site visitor by CHAP Management staff
• Administrative evaluation by CHAP Staff
• Annual self-evaluation by the site visitor

Planning and scheduling site visits:

All visits to Medicare home health and hospice organizations will be unannounced if agency applies for "deemed status." All site visits for home medical equipment (HME/DMEPOS) accreditation will be unannounced. For any multi-service organization with a deemed service, the site visit will be unannounced. Visits will be scheduled within the expected time frames as determined by the Board of Review and CHAP Staff. Non-Medicare certified organizations may have prior knowledge of the date of scheduled visit.

Types of three-year accreditation site visits include the following:

Accreditation (1 Visit per 3 Year Cycle)	Initial Medicare Certification (3 Visits per 3 Year Cycle)	Other Visits (as needed)
Initial (Year 1) Site Visit includes the completion of the Self Studies Annual Site Visit (Year following year 3 of 3 Year Cycle)	Initial (Year 1) Site Visit includes the completion of the Self Studies Year 2 of a 3 Year Cycle Year 3 of a 3 Year Cycle	Focus Visit Complaint Investigation Visit

The Entrance Conference:

Upon arrival at the organization, the lead site visitor announces the arrival of the site visit team and requests to meet with the CEO and the designated members of the administrative team. The purpose of the Entrance Conference is to:

• Demonstrate the preparedness of the team to conduct the site visit in a knowledgeable and organized manner
• Facilitate a professional and positive experience for the organization during the site visit
• Explain the site visit activities and time frames for completion
• Engage all levels of the staff in the accreditation process

The length of time for the Entrance Conference is approximately 30 minutes.

The lead site visitor will take responsibility for the following:

• Confirming specific information pertinent to the organization being accredited
• Explaining the CHAP site visit process
• Informing the organization of the materials, documents, and statistical information to be submitted to the site visit team
• Assuring the confidentiality of information provided by the organization
• Explaining the consultative component of the site visit
• Distributing and collecting required paperwork
• Assigning organizational responsibilities with defined time frames for completion
• Establishing the time and place for the Exit Conference

The applicant organization is responsible for the following:

• Orienting site visitors to the physical plant
• Introducing site visitors to key staff
• Designating a primary contact person to work closely with the site visitors
• Providing reasonable workspace for the site visit team
• Notifying clients and obtaining verbal permission for the home and service site visits
• Transporting site visitors to home and service site visits
• Providing directions for travel to remote service sites as necessary
• Responding in a timely manner to requests from site visitors for accreditation related documents and statistical data
• Arranging for interviews with key personnel
• Arranging for observational experiences for site visitors
• Arranging for the Entrance Conference and Exit Conference, place, time, and participants
• Providing copies of video/audio tapings of the Exit Conference at the close of the site visit

Client Visits:

Site visitors make visits to clients receiving care and services in the home setting and to clients receiving care and services in community-based settings. The purpose of these visits is to:

• Verify that the care and services provided by the applicant organization meets CHAP Standards
• Validate that the care and services provided is consistent with the organization's policies
• Ensure that direct and contracted care and services comply with the client's plan of care/service
• Determine the client's reaction to and satisfaction with the plan of care/services

Selection of Client Visits

The organization will provide a list of clients scheduled for visits. The site visitor will select a random stratified sample of clients to be visited, taking into consideration diagnosis, payor source, service mix, and willingness of clients to grant these visits. For large organizations with multiple service sites, other considerations include travel time, distance, and previously visited service sites.

Permission for Client Visits:

The organization contacts clients and receives verbal approval for the visit prior to the site visitor arriving on site. The site visitor is responsible for obtaining written approval from the client or client representative using the "Consent for Home Visit" form for home visits and/or the "Consent for On-Site Visit" form for Public Health site visits. The client has the right to refuse a visit from the site visitor.

Additionally, in the event the organization feels that a site visit would not be reasonable for a given client, the site visitor will respect the decision. A copy of the signed consent is distributed to the client and the organization. The original is returned to the CHAP office as a part of the Site Visit Report. The function of the site visitor when making a client visit is to observe the activities and interview the client/representative in a non-disruptive manner.

Telephone Surveys:

During the course of the site visit, the site visitor may conduct telephone surveys of discharged clients and major referral sources to determine the level of satisfaction with the services and products provided by the organization. Sub-contractors to the organization may also be contacted to address the satisfaction of the contractual relationship and assess the level of compliance with the organization's policies and CHAP Standards.

Exit Conference:

At the conclusion of the site visit, the lead site visitor conducts an Exit Conference with input from designated members of the site visit team. Senior administrative personnel determine attendance by the organization's staff. CHAP encourages the participation of management and supervisory staff as well as members of governing boards and advisory committees. The purpose of the Exit Conference is to:

• Applaud the agency for voluntarily seeking accreditation
• Extend appreciation to the organization for the cooperation and assistance to the site visit team
• Bring closure to the site visit
• Delineate the findings of the site visit as they relate to the CHAP Standards
• State the level of compliance with the Medicare Conditions of Participation for Medicare certified agencies through CHAP’s deeming authority
• State the site visit team recommendation to the Board of Review
• Explain the function and accrediting authority of the Board of Review
• Provide an opportunity for the organization to ask questions or respond to the presentation

Pre-Billing Report of CHAP Site Visit:

At the conclusion of the formal Exit Conference, the lead site visitor completes the "Pre Billing Report" and obtains the signature of a duly authorized official of the organization. The lead site visitor faxes the completed form to the CHAP office at the end of the last day on site. The original is returned to the CHAP office with the site visit report.

Consultation

Following the close of the formal Exit Conference, the lead site visitor will provide consultation to the organization. The administrative personnel of the organization will set the consultative agenda.

Step 4. The Board of Review

The Site Visit Report is the legal document that states the organization's level of compliance with the CHAP Standards. The Centers for Medicare & Medicaid Services (CMS) forms become a part of the Site Visit Report for home care and hospice organizations that have elected to receive Medicare Certification through CHAP’s "deeming authority."

The Site Visit Report and all substantiating data and documents are reviewed by the Board of Review at the next regularly scheduled meeting. The main focus of this review is on required actions cited and the site visit team recommendation regarding accreditation status of the organization.

Board of Review Determinations (as communicated in the report cover letter):

• Accreditation without Required Actions
• Accreditation with Required Actions
• Accreditation with Required Actions and a Progress Report Due
• Accreditation with Required Actions, a Progress Report due, and a follow-up Focus Visit
• Accreditation with Required Actions and a follow-up Focus Visit
• Defer Accreditation (initial accreditation only)
• Deny Accreditation (initial accreditation only)
• Formal Warning (continued accreditation only)
• Withdrawal of Accreditation (continued accreditation only)