Patient Care/Mastectomy FAQs

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.

The following documents must be uploaded and submitted with your online application.

•        All non-ABC certificates and licenses (if applicable)

•        Legal documentation of ownership (e.g., Articles of Incorporation, IRS tax form)

•        Business license, business permit or occupancy permit

•        Copy of surety bond

•        Your ENTIRE Policy & Procedure Manual

•        Your ENTIRE Employee Manual

•        Mission statement
  
  

These documents must be submitted within the online application portal NOT via email, fax or regular mail. For larger documents, you can split them into multiple scanned sections or zipped files. We understand that these can be very large files, but your entire P&P manual must be submitted. The submission of partial documents does not meet our requirements. If you have combined some of your documents, such as your policies, procedures and employee manuals into a single document, that is perfectly acceptable.

Surveyors review your uploaded documents prior to conducting your facility’s onsite survey. Being able to review documents in advance makes the survey process more efficient and allows time for the surveyor to provide valuable feedback in person.

You should review and update your manuals every year, and it is essential that you maintain electronic copies of these documents. Your contingency plan should prioritize accessibility to these documents. We strongly recommend having electronic backups or scanned versions readily available, ensuring seamless access when needed.

You must have the appropriate personnel on staff before submitting your application.

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.

If you plan to move during the accreditation process and have already submitted your application, please be aware that your onsite survey is unannounced and unscheduled to be compliant with Medicare requirements. If your survey occurs before your move, then you must submit another application and onsite survey. 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.

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.

No. CMS requires that all patient care accreditation surveys be unannounced and unscheduled. For central fabrication facilities, surveyors will schedule the survey with the survey contact.

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

Surveys are not conducted on federally recognized holidays or their observed days. If your facility will be closed for a state or city recognized holiday, please email us at accreditation@abcop.org.

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).

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

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.

Most accreditations are valid for up to three years.

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.

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.

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.

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).

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.

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!

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

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.

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

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.

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

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!

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.

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.