Your guide to accreditation terminology.


Advisory group — A group approved by the governing body to advise the organization on professional issues and to assist the organization in maintaining liaison with other health care providers in the community.

Affiliate — Persons or organizations who are associated with an agency as part of a formal business structure or through contractual or service agreements such as providers of billing, therapy or other services.

Assessment — A systematic collection of objective information data obtained through interview, observation and physical examination, as well as information from other sources to thoroughly evaluate an individual, situation or event.

Basic personal care services — Services provided by trained and or competency tested personnel to stable consumers with non-medical needs under the direct or indirect supervision of a registered nurse. 

Census — An active patient census is for those consumers who are currently receiving care, service and/or products.

Certified home health aide services — Services provided by aides who have been trained and/or competency-tested, as well as by certified nursing assistants who have completed a state-approved training program for certified nursing assistants and have received additional home care training and competency testing. 

Competence — Possession of required skill, knowledge and experience to perform the duties required. 

Competency testing — Written testing and/or direct observation of an individual performing a task or procedure. 

Consumer — The end user or recipient of the care, services, products, equipment or supplies provided by an organization. Consumers may include individuals, families, groups, other health care entities and communities.

Contractor/contract employee — An individual or organization providing services under arrangement to the organization. Persons providing services under contract with another business entity, as well as independent contractors, are considered contractors providing services under arrangement.

Coordination of care — Sharing of information between providers to ensure that the consumer’s needs and preferences for care are understood and to enhance the quality of care, services and/or products provided.

Criterion — A statement that defines in detail the requirements of the standard.

Direct employee — An employee hired by the organization for whom payroll taxes are paid and who receives a W-2 form annually.

Direct supervision — Having a reporting supervisor for the position rendering services. Direct supervision does not require that the supervisor is present when care is being provided. 

Element — A component of each criterion that delineates requirements.

Employees — Individuals hired by organizations, as well as volunteers of the organization.

Evidence guidelines — Guidelines and examples of evidence used by organizations and Site Visitors in determining organizational compliance with standards.

Executive staff — At a minimum, the executive staff includes the Senior Leader and the alternate to this position. Job titles may include but not be limited to CEO, President, Executive Director and Administrator, among others. 

Governing body — A person or persons with legal authority, accountability and responsibility for the administration and performance of an organization.

Healthcare Associated Infection (HAI) — Infections that are acquired during the course of receiving treatment for another condition in a health care setting.

Home/environmental support services — Services provided by trained/competency-tested personnel including homemakers, chore workers, companions, sitters and environmental workers. Services include homemaking, housekeeping and other activities inside and outside the home that support consumer independence, are assistive in scope and do not require hands-on personal care activities.

Indirect supervision — General, overall responsibility for the care/services provided to consumers. 

Information system — The methods used by the organization to manage and organize data. The system may be electronic or paper-based.

Inservice — Training and education taking place during the course of employment to assist in the development of skills.

Interdisciplinary team/interdisciplinary group — Comprising a physician, registered nurse, social worker and pastoral or other counselor. Additional members may include physical therapist, occupational therapist, speech language therapist/audiologist, dietitian, pharmacist, home health aide/homemaker and volunteer.

Introductory period
— A time frame identified by the organization that allows for the new employee to be instructed in, and become familiar with, the position. This time frame may also be referred to as a probationary period.

Medication reconciliation — A process used to accurately identify all medications taken by the consumer, including over the counter, herbal and home remedies, and resolve inconsistencies and real or potential problems in a consumer’s medication regimen in consultation with the physician.

Orientation — Instruction and education provided to employees upon beginning a new job.

Paraprofessional — A non-professional employee with a specified level of competency, supervised by a health care professional.

Periodic — Recurring at regular intervals; i.e., the organization defines the timing of periodic events.

Plan of care — A document detailing of the needs of the consumer and the interventions that will be provided by the organization to assist the consumer in achieving desired outcomes. 

Protocol — A set of rules and procedures to be followed.

Readiness — All requirements for scheduling an accreditation site visit have been met.

Scope of services — The range of services provided by the organization.

Screening — Systematic examination or assessment used to determine the presence of a particular disease or condition. Screening methods may include performance of a medical procedure or other methods of evaluation, such as completion of standardized assessment tools.

Senior Leader — The leader with the highest level of authority in the organization as identified in the organizational structure.

Service unique — Areas of care, services, equipment or supplies provided to consumers.

Site Visit — An on-site visit to the provider organization by CHAP Site Visitor(s) for validation that CHAP Standards of Excellence are met, to investigate a complaint or to follow up on implementation of the Plan of Correction.

Standard statement — A blueprint for success that recognizes excellence and is a model or example for practice.

Sub-element — Additional statements that provide more definition of selected elements.

Supervisor — Person who has authority to hire, fire and provide formal feedback; is the next step in chain of command; directs daily work and/or provides more global direction; and has final responsibility for performance of subordinate staff.

Tag items — Identifiers used by the Centers for Medicare and Medicaid Services to indicate non-compliance with one or more Medicare Conditions of Participation, or standards. It is cross-referenced to a section of the Code of Federal Regulations.

Telemedicine — Remote monitoring via electronic communication to collect data and monitor the consumer’s health and clinical status. Telemedicine may be used to supplement home visits.

Transitions of care — The movement of consumers between practitioners or care settings.

Unduplicated admissions — The number of unique consumers admitted during a specified time period.