Joan Zinter, CPO, Senior Surveyor

When surveying for ABC facility accreditation, I frequently note that affiliate patient care locations often get less attention than primary locations when it comes to ensuring standards compliance. While accreditation compliance activities are generally documented at a business’s primary site where most of the corporate, business and administrative functions occur, it’s important to coordinate these compliance activities across all of a business’s patient care locations.

This lack of affiliate site compliance often reflects a breakdown in communication and the location, primary or affiliate, will ultimately be responsible for providing documentation to prove compliance. The first corrective action to improve compliance at affiliate sites is to determine which accreditation standards will be delegated and which staff members will be responsible for their completion. The second action is to decide how the primary location will determine whether these tasks have been successfully completed each year.

We recommend having compliance documents for affiliate sites in one location to allow surveyors to easily locate them. Compliance documentation helpful in completing an affiliate survey includes:

• Federal Tax ID Number (AD.1)
• Business Permits from State and Local Authorities (AD.1.1)
• Liability Insurance for the Specific Location (AD.5)
• Surety Bond for the Specific Location (If Applicable) (AD.5)
• PTAN Numbers that Identify the Affiliate Location (AD.5)
• Practitioner Certification or Licenses (HR.4.1, HR.4.2)
• Privileging Documentation (HR.6)
•  Annual Facility Safety Inspections (FS.1.1)
• Machine Maintenance Logs (PS.3.1)
• Evacuation Plan and Drills Documentation (FS.3.2, FS.3.2.1., FS.3.2.2)

If you haven’t been documenting the items noted above at all your affiliate patient care locations and received non-compliant scores during your survey, now is the time to invest in an action plan to ensure it doesn’t happen again. Affiliate site facility accreditation compliance is easy when you've got a plan in place.