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Frequently Asked Questions

 

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Frequently Asked Questions

 

1. What do AAAHC standards cover?

 

2. Why do I need to obtain a new Handbook each year?

 

3. How does an organization prepare for an accreditation survey?

 

4. What kind of accreditation decisions are there? /What are the different possible outcomes of the survey?

 

5.Who are Accreditation Association surveyors? What are their qualifications?

 

6. What does the AAAHC use to evaluate organizations?

 

7. How are accreditation decisions reached?

 

8. How long does it take to reach a decision?

 

9. How long does it take to schedule the survey?

 

10.  How many days should we expect a surveyor to be here?

 

11. How much is the survey fee?

 

12. What is the benefit of having an AAAHC/Medicare Deemed Status survey and why should my organization seek this survey through AAAHC? 

 

1.  What do AAAHC standards cover?

 

There are 8 core chapters of standards relating to basic aspects of ambulatory care: Rights of Patients, Governance, Administration, Quality of Care Provided, Quality Management and Improvement, Clinical Records and Health Information, Infection Prevention and Control, and Facilities and Environment

In addition, there are 19 chapters of adjunct standards which are applied based on the services provided by the organization.

For more information on standards and revisions to standards, please visit this link.

About AAAHC Standards

To obtain the complete manual of AAAHC standards, purchase the AAAHC Accreditation Handbook for AAAHC Accreditation Handbook for Ambulatory Health Care. Please visit this link to purchase the Handbook. Publications

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2.  Why do I need to obtain a new Handbook each year?

The AAAHC standards are revised annually in tandem with evolving trends in ambulatory health care and based on feedback from the public, accredited organizations, AAAHC surveyors, and AAAHC Board member organizations. Accredited organizations are expected to maintain their operations in compliance with current standards throughout their terms of accreditation. Obtaining a new Handbook each year will ensure currency with accreditation standards.

This year, the Handbook has undergone many revisions and updates and we would like to share some of them with you.

•   THREE-RING BINDER STYLE: The Handbook has been changed from a bound book to a three-hole punched format. This will allow users to add reference materials and remove pages such as sample worksheets which can be photocopied.

•   POLICIES/PROCEDURES: The Accreditation Policies and Procedures have been simplified and divided into two sections. The first section contains general policies applicable to all organizations. The second section contains additional policies and procedures for ambulatory surgery centers seeking Medicare Deemed Status surveys.

•   SELF-ASSESSMENT: The Self-assessment Manual has been incorporated in the Handbook and you will see a compliance rating scale next to each standard. Organizations seeking accreditation may use this self-assessment feature and its summary table in preparing an action plan to address areas identified as less than compliant.

•   CMS STANDARDS: In those cases where an AAAHC standard is interchangeable with a Medicare requirement, the AAAHC standard is marked with a CMS icon throughout the Handbook, worksheets and forms. AAAHC standards so marked apply to Medicare certified organizations undergoing non-Medicare as well as Medicare Deemed Status surveys. In chapters containing Medicare requirements that exceed AAAHC standards, the Additional Medicare Requirements are located at the end of the chapters and printed in blue ink as in past editions. NOTE: These Additional Medicare Requirements apply only to organizations undergoing Medicare Deemed Status surveys.

•   CHAPTER 7: A new core Chapter 7 entitled, Infection Prevention and Control and Safety, has been added.

•   APPENDICES: Former Appendices A through F have been re-ordered, and a separate section now contains sample worksheets and forms.

•   WORKSHEETS AND FORMS: These individual sample forms and worksheets, previously Appendices D-J, have been revised in accordance with the 2010 standards, but also include any corresponding Additional Medicare Requirements. These forms, provided in an interactive PDF format, allow an organization to conduct self-assessments using documents similar to those used by surveyors during the survey. NOTE: These worksheets are not intended to serve as a substitute for an organization’s review and assessment of compliance with all applicable AAAHC standards. To assist organizations further, the worksheets and forms are provided on a separate CD that is included with each hardcopy Handbook purchase. The sample worksheets and forms are already included on the CD version of the Handbook.

•   MEDICARE DEEMED STATUS SURVEY: A step-by-step guide for organizations considering Medicare certification, “Understanding, Planning, and Preparing for an AAAHC/Medicare Deemed Status Survey.”

•   RESOURCES: A Resources section, presented in chapter order, has been added and includes a list of web sites organizations may find helpful as they address compliance. Additionally, the listed resources may be helpful to surveyors as they provide consultative information to organizations.

•   GLOSSARY: A glossary has been added containing a variety of terms that organizations may find helpful.

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3. How does an organization prepare for an accreditation survey?


- Obtain a copy of the AAAHC standards by ordering the latest edition of the AAAHC Accreditation Handbook for Ambulatory Health Care and review the standards to review your organization’s compliance. The Handbook will provide you the tools to conduct a self-assessment of the current level of compliance to the AAAHC standards. Using the Handbook will help identify and improve your organization’s processes and practices to comply with the standards.

 

- You may wish to attend one of AAAHC’s educational programs conducted four (4) times a year in different parts of the country. These programs assist organizations to prepare for the accreditation process. Please visit this link for further information about these programs. Education Programs

 

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4. What kind of accreditation decisions are there? /What are the different possible outcomes of the survey?

 

After the on-site survey has been conducted, organizations may be granted one of the following terms of accreditation:

a)     Three Years
The AAAHC awards accreditation for three years when it concludes that the organization is in substantial compliance with the standards, and the AAAHC has no reservations about the organization’s commitment to continue providing high-quality care and services consistent with the standards.

b)    One Year
The AAAHC awards accreditation for one year when a portion of the organization’s operations are acceptable, but other areas need to be addressed and the organization requires time to achieve and sustain compliance with AAAHC standards. The organization must have a re-survey within ten (10) months from the previous survey date to avoid a lapse in accreditation. The re-survey will not necessarily be limited to the deficiencies noted in the previous survey report; all core and applicable adjunct standards will be reviewed.

c)     Six Months
The AAAHC awards a six-month term of accreditation when it concludes that the organization is in substantial compliance with the standards but it is not eligible for a one-year term of accreditation because the organization does not meet certain requirements (e.g., the organization has not been operational for six months).

The AAAHC also awards a six-month term of accreditation to organizations that are not in compliance with the standards and the organization’s demonstration of continued compliance with the standards is not sufficiently well established to grant a longer term of accreditation. The organization, however, demonstrates the commitment and capability to correct identified deficiencies within six (6) months. The organization must have a re-survey within five (5) months from the previous survey date to avoid a lapse in accreditation. The re-survey is not necessarily limited to the deficiencies noted in the previous survey report; all core and applicable adjunct standards will be reviewed.

 

d)  An organization may be denied accreditation

     if it is not in compliance with the standards.

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5Who are Accreditation Association surveyors? What are their qualifications?

 

Accreditation Association surveyors include physicians, dentists, podiatrists, pharmacists, nurses and administrators who are actively involved in ambulatory health care. They must be experienced professionals who meet stringent recruitment qualifications and undergo AAAHC’s rigorous application process. Applicant surveyors are screened by the AAAHC Surveyor Training and Education Committee, trained by the Accreditation Association, and based on favorable evaluation, approved by the Board of Directors.

Surveyors also have to successfully complete a re-training session to be re-credentialed every two years. Included for consideration of re-credentialing are evaluations of each surveyor’s performance based on feedback from organizations they surveyed, as well as surveyors they performed surveys with.

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6. What does the AAAHC use to evaluate organizations?

 

Compliance with the standards is measured through:

 

1. Documented evidence    

 

2. Answers to detailed questions concerning
    implementation

 

3. On-site observations and interviews by
    surveyors The overall compliance with AAAHC

    standards determines the length of the
    accreditation term.

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7. How are accreditation decisions reached?

 

The AAAHC carefully reviews information supplied by the organization, obtained during the survey and any other relevant information before making an accreditation decision. A surveyor, staff member or member of the AAAHC Board of Directors who is in any way affiliated with an organization, or whose participation represents a conflict of interest, is not allowed to participate in deliberations or voting relative to the accreditation status of that organization. The organization will be notified in writing of the accreditation decision and will receive a detailed report of the survey findings. 

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8
. How long does it take to reach a decision?

Typically, a decision is rendered within 4-8 weeks after the survey.

Typically, on average, a decision is completed in three weeks or less.

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9. How long does it take to schedule the survey?

 

It takes approximately 30 days to confirm a survey upon receipt of a completed Application for Survey.

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10. How many days should we expect a surveyor to be here?

The number of days required for the survey depends on the size and complexity of the services your organization provides. Our scheduling office will be able to advise you of the duration of the survey and the number of surveyors after reviewing your application. Typically, surveys are one or two days.

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11. How much is the survey fee?

 

There is a non-refundable application fee of $775. The survey fee itself depends upon the size and range of services offered by the organization and is not determined until an application is determined by AAAHC to be complete. For more information, please contact AAAHC at (847) 853-6060. 

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12. What is the benefit of having an AAAHC/Medicare Deemed Status survey and why should my organization seek a this survey through AAAHC? 

 

When an organization requests an AAAHC/Medicare Deemed Status Survey, they may be able to achieve AAAHC accreditation, as well as be eligible to obtain Medicare certification. This combined survey allows organizations to maintain their current Medicare Certification or obtain Medicare Certification for the first time.

 

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For further information download the FAQs Regarding AAAHC/Medicare Deemed Status Surveys below:

 

 

Download FAQs Regarding AAAHC/Medicare
Deemed Status Surveys
Adobe's Portable Document Format (PDF) - Note: You must have Adobe Acrobat software on your computer to view a PDF file.