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Patient Care/Mastectomy FAQs

Can I provide services prior to being accredited?

Yes – Your facility must be currently seeing patients. New businesses must have a minimum of five complete patient charts, from either cash paying patients or from those wishing to use a third-party payer. However, be sure to check with the third-party payers to make sure your facility meets their requirements prior to billing.

Can I apply for accreditation without having board certified or licensed staff members?

You must have the appropriate personnel on staff before submitting your application. Please refer to the Central Fabrication Accreditation Guide for an overview of the credentialing requirements.

Do I need to apply for all scopes of service that I am providing or just specific ones?

You must apply for accreditation for all of the services your facility provides regardless of whether your facility is billing any third party, including Medicare/Medicaid, this requirement only applies to those services for which we offer accreditation.

What if our facility is moving?

If you plan to move during the accreditation process and have already submitted your application, please place your application on hold. We must survey each physical address, so we recommend you complete your move prior to submitting your application, this eliminates the need to submit additional applications or fees.

What if I have contracts that are pending accreditation?

Please include a statement with your online application detailing any pending contracts. We do our best to accommodate all requests, but this is not always possible.

Do I need to be compliant with all of the standards prior to applying?

No – you are only required to comply with the standards relevant to the services your facility provides. Please use the Custom Standards Tool to get a personalize list of standards you must comply with based on the services your facility provides.

Onsite Surveys
Can I schedule my survey?

No. CMS requires that all surveys be unannounced. However, ABC will provide a courtesy four-week window in advance of your survey. We do schedule accreditation surveys for central fabrication facility accreditation.

What if I'm not ready for the survey?

DO NOT submit your application until you are ready for your on-site survey.

If you’ve already submitted your application and don’t think you are ready for your on-site survey, we recommend that you place your application on hold until you feel you are prepared. Please note that placing your application on hold removes you from the survey process. Once you remove your hold, your application resets to that date.

You must request hold status in writing 30 business days in advance. You can request a maximum six month hold on your application; from the date your application was approved. In addition, you must notify us in writing when you are ready to remove the hold. We will send you a courtesy reminder prior to the deadline, but if we do not hear from you, you must resubmit your application along with the appropriate fees.

Can a survey occur on a holiday?

No, surveyors do not conduct surveys on major federally observed holidays or their observed days. However, if you plan to close your offices for additional days before or after holidays, it is your responsibility to notify us.

What if I know I’m going to be out of the office?

New facilities, including affiliate add-ons, are not eligible to submit any blackout dates as limited availability can delay your on-site survey.

If you are renewing your accreditation, you can submit blackout dates. A total of 14 total blackout dates may be requested in a six-month period and we will not send a surveyor during those dates. Submit the Blackout Date Request form online by the deadline noted in your application receipt email.

What if I have an emergency and need to be away from my office during regular business hours?

You should have a contingency plan in place for emergencies. If your contingency plan falls through, you should place a visible note outside your door with your contact information (name, cell phone number).

Does the facility owner need to be present during the survey?

No. As long as someone can allow the surveyor on site, answer questions and access documents, the owner is not required to be present.

When will I get my survey results?

Results are emailed and mailed 4-6 weeks after your on-site survey. If you have questions about the timeframe or have not received your results after 6 weeks, please email accreditation@abcop.org with your facility’s name and address and we will resolve the issue.

How long will my mastectomy-only accreditation be effective?

Most accreditations are valid for up to three years.

Can I get additional copies of my accreditation certificate?

Electronic copies can be downloaded any time via the links provided in your decision email. Hard copy reprints are available for $25 each and can be ordered directly from your facility’s MY ABC account.

What is privileging?

Privileging refers to giving an individual permission or ‘privileges’ to engage in specified clinical activities. ABC defines how a credentialed person may be allowed, under supervision, to provide items and services outside of their scope of practice. That privileging process is described in detail in the ABC Orthotic, Prosthetic and Pedorthic Scope of Practice.

Are non-certified individuals allowed to provide any services?

Certain patient care tasks can be delegated to non-credentialed individuals. The new definition for Support Personnel details what aspects of patient care can be delegated to non-credentialed persons. For more information, refer to the definition of Support Personnel.

My non-certified individual is providing OTS; do they need to be privileged?

No. Off-the-shelf items can be provided by any staff member; no certification is required. Any item that has ‘off-the-shelf’ in the Medicare HCPCS L-code descriptor is considered an off-the-shelf item. This does not include diabetic HCPCS codes (e.g., A5500).

Corrective Active Plan (CAP)
Is there any cost to submit a CAP?

No. However, if you are required to have an additional on-site survey, you will be notified in your accreditation decision letter. Resurveys do require additional fees.

What should be included in my CAP?

Please use our CAP template .  Your CAP should include:

  • Your facility’s name and address(es)
  • A written plan that address all standards marked Partially Compliant (P) or Non-Compliant (N)
  • Documentation/evidence for each N and P standard
  • Copies of all completed documentation (forms, patient notes, logs, training notes, etc.) showing that changes have been made. No blank templates or forms with sample data!
  • Copies of any meeting minutes or agendas that show that training has been completed
  • Copies of updated policies – please don’t send your entire Policy and Procedure manual only copies of the policies you have updated.

Note: If a completed annual review for your facility is part of the documentation needed for your CAP, we ask that you go ahead and perform the review with the information you have available, even if the scheduled date for that review is after your CAP deadline. This will help us better evaluate your accreditation status.

Remember - DO NOT send original documents, as items submitted to ABC will not be returned. DO make sure all PHI is blacked out before sending it to us!

Once complete, how do I submit my CAP?

Please email your CAP to accreditation@abcop.org or fax to (703) 842-8027.

What is the timeline for CAP submission and review?

Your facility’s CAP is due within 60 days of your decision email. Your deadline will be stated in your decision email and decision letter.

What is a Corrective Action Plan?

A document submitted to ABC demonstrating your facility’s compliance with one or more standards that were in question after your on-site survey.

When is a CAP required?

ABC may request a CAP for any of the following reasons:

  • You receive an overall failing score
  • You receive an overall passing score but have deficiencies which require additional attention
  • You miss standards that are considered mandatory, regardless of overall score. These standards are:
    • AD.5, AD.6
    • HR.6, HR.6.1
    • PC.6.9, PC.6.9.1, PC.9.1
    • PM.10
    • FS.3.2.2
    • CB.1, CB.4.1
    • HR.4.1, HR.4.2, HR.8.2, HR.8.3

If we request a CAP, your accreditation is not final until your CAP has been approved. If you fail to submit a CAP by the deadline, your application will be denied, and any existing accreditation may be revoked. You will then need to submit a new application, including all fees, for an additional on-site survey.

What is the proper format for CAPs?

Address each standard marked N (Non-Compliant) or P (Partially Compliant) in the following example format:

Standard: FS.3.2.2
Description of
corrective action:
We have now completed a yearly fire drill. In the
future, these will be completed on the first Monday of December.
Documentation: A completed copy of the fire drill report, including signatures of employees in attendance.
Can I just submit my entire Policies and Procedures Manual?

No. You must use the format as described above. Any documentation submitted to ABC is not returned, so please do not send any Policy and Procedure manuals!

How will I know that you have received my CAP?

Upon receipt of your CAP, we will send you an email confirmation. If you have not received an email confirmation, please email us at accreditation@abcop.org.

What if my CAP is incomplete?

If we need more information to make a final decision, you will have one more opportunity to submit documentation. You will receive a second request letter with a new deadline and details about what information is still needed.

Need more help? Send us a note.