Mastectomy Facility Accreditation Guide

Full Approval

ABC Facility Accreditation is awarded when the overall score is within a passing range and no significant compliance issues are found. Facilities with full approval will receive an emailed decision with access to an electronic letter, survey report, and certificate. A decision letter and certificate with a three-year accreditation will be mailed to your primary facility.

Corrective Action Plan (CAP) Decisions

If your surveyor found deficiencies and/or if your facility’s overall score is not within a passing range, your facility may be given the opportunity to submit a Corrective Action Plan (CAP). A CAP is a document that is submitted to ABC demonstrating your facility’s compliance with the standard(s) in question. CAPs are reviewed and approved on a case-by-case basis; submitting a CAP does not guarantee accreditation. The length of accreditation awarded with a CAP requirement may vary from one to three years dependent on review of the survey results. Failure to submit an approved CAP within the allotted time period will result in revocation of your accreditation (if previously granted prior to the submission of your CAP). There are no fees associated with CAP submission and they may be mailed, emailed to accreditation@ABCop.org.

Pass with a Corrective Action Plan requirement

If your facility’s overall score is within a passing range but had deficiencies, you will be issued an accreditation that is contingent on an approved CAP. During the time of review, your facility is considered accredited.

Fail with a Corrective Action Plan requirement

If your facility’s overall score is not within the passing range, you may be given the opportunity to submit a CAP. During the time of review, your facility is not considered accredited. After the review of your CAP, you may be granted accreditation.

Corrective Action Plan Timeline

CAPs are due within 60 days of the decision email date. Your accreditation decision, containing your CAP request, will be emailed and mailed to you. Failure to submit a CAP by the deadline will result in denial or revocation of accreditation. Due to the intensive nature and volume of CAP reviews, it takes approximately 8-10 weeks to review each CAP.

Incomplete Corrective Action Plans

If your initial CAP does not adequately demonstrate compliance with missed standard(s), we will inform you via email and/ or letter. If additional information is necessary in order for us to make an accreditation decision, we will make one additional request for follow-up materials within a specified timeframe. All materials are due by the deadline stated in the correspondence.

Supporting Corrective Action Documentation and Format

Your CAP must include supporting evidence that shows how changes have been implemented to address each missed (P or N) standard. This can include completed forms, logs, training notes, annual reports, patient notes (with patient identifying information removed) and meeting minutes. Your facility’s Policy and Procedure manuals will not be accepted as a CAP; policies should only be submitted when directly relevant to the surveyor comment or the standard being addressed. All documentation is treated in accordance with HIPAA, privacy and security regulations. For each missed (P or N) standard, please use the format shown in the example below.

1. Standard: FS.3.2.2

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.

3. Documentation: (Include a copy of the completed fire drill report, including signatures of employees in        attendance and analysis of the drill.

Denial

A facility may be denied accreditation for multiple reasons. Some of the most common causes for accreditation denial are:

• The surveyor was denied access to the facility and/or documentation
• Facility was closed or otherwise unavailable for the onsite survey
• Submission of two CAPs that did not adequately address the issues in question or the CAP was not submitted by the deadline.

If your accreditation is denied, you must reapply and be resurveyed in order to attain ABC Accreditation. When you reapply, you must submit a new application with the appropriate fees.

Accreditation Effective Dates

Accreditation effective dates for new and renewing facilities are determined as follows:

• First day following your survey, if your facility passes the initial survey
• Date reaccreditation application was received by ABC, if your facility is accredited and passes the reaccreditation survey
• Date that the CAP was received, if the plan satisfies the deficiencies identified

The accreditation effective date for service or affiliate add-ons is the date the application was received by ABC, if your facility passes the respective add-on survey.

Reporting to Medicare and Other Third Parties

ABC notifies CMS weekly of all accreditation decisions once they are finalized. Additionally, we may notify other payers or interested parties of the status of your facility’s accreditation as well as issue public statements concerning the accreditation of applicants. Facilities that are past-due on annual or accreditation fees are not reported to Medicare, verified with other third parties and are not considered in good standing.

Accreditation Decision Review

All onsite survey findings that result in a limited, denied or revoked accreditation are automatically reviewed by the ABC Facility Accreditation staff. ABC staff has the authority to request additional information from you or your surveyor before reaching a final decision. If you believe your facility’s accreditation is limited, denied or revoked as a result of incorrect information, you may formally appeal the decision.

Appeals Process

You have 15 days from the receipt of the accreditation decision to submit a written appeal to the Facility Accreditation Committee. Your appeal must be mailed via certified mail, return receipt requested or by verifiable overnight express mail service to:

American Board for Certification in Orthotics, Prosthetics & Pedorthics, Inc.                                                        Attn: Facility Accreditation Department                                                                                                                              330 John Carlyle St., Suite 210                                                                                                                                          Alexandria, VA 22314

Your appeal must include the new evidence or relevant documentation that was not provided during the initial survey. If you do not appeal the decision within the 15-day time period, the accreditation decision will be final.

You will receive notification of the Committee’s decision on your appeal within 45 days of its receipt by ABC. Should you not be satisfied with the decision, you may submit a second appeal to the ABC Board of Directors by sending another certified, written appeal to the ABC offices within 15 days of receipt of the Committee’s decision. You will be notified of the board’s decision within 60 days of receipt of your request. The decision of the board is final.

Accreditation Fees

Current accreditation fees may be found by visiting the Patient Care Accreditation section of the ABC website. All accreditation fees are non-negotiable and non-refundable.

Accreditation fees are set by the ABC Board of Directors. ABC reserves the right to adjust accreditation fees and establish the effective date of change. ABC also reserves the right to adjust accreditation fees based on new or validated information obtained during the survey process, which may affect the type of survey, the type of accreditation awarded and/or the number of survey days required. Final accreditation determination is contingent upon receipt of all fees.

Application Fees

The accreditation application can be accessed by logging into your facility’s account on the ABC website. Application payment for all programs and primary and, if applicable, affiliate and/or warehouse/ administrative locations must be provided in order to submit your application to ABC. Additional fees are required for any accreditation program that is added to your main accreditation. Full payment must be submitted with your application. Your facility will only be added to the survey queue if your application is complete and fees are received in full. The fees associated with the application encompass application processing and the onsite survey. We do not charge fees for any travel expenses incurred by surveyors.

Annual Fees

All accredited facilities are assessed annual fees. Notifications are emailed in September and mailed in October of each year. Your annual fees are due on December 1st. Your current accreditation status is dependent on the timely receipt of these fees. Failure to submit annual fees may incur any or all of the following:

a. Removal from ABC’s weekly Medicare report

b. Removal from ABC’s Directory

c. Inability to verify your facility’s accreditation with all third-party payers

d. Revocation of facility accreditation

Certificate Reprint Fees

If you wish to obtain an additional accreditation certificate, you must login to the facility’s MYABC account to submit request and pay the associated fee. Your facility must be in good standing in order to process your request.