Mastectomy Facility Accreditation Guide

The Basics

All applicants must meet the basic eligibility criteria as well as become compliant with the Standards listed in this Guide. Your compliance is determined by a review of your application materials, a consultative onsite survey, and a final validation of your surveyor’s findings. The onsite survey is conducted by professionally trained and qualified surveyors. As required by CMS, all surveys for patient care accreditation are unannounced and unscheduled and occur during your posted business hours. By submitting your application, you declare yourself ready for an onsite survey at any time. Surveys will not be rescheduled due to emergency closure, staff unavailability or lack of readiness. If you deny the surveyor access to your facility and/or essential paperwork or if your facility is closed during posted business hours, you must resubmit an online application and include all accreditation fees.

Types of Surveys

Initial Survey (First-time Applicants)

If you are considering accreditation for your facility, we encourage you to review this Guide and complete the Pre-Application Checklist to help you determine if you are eligible for ABC Accreditation. To be placed in the queue for the initial survey, you must submit a request to create an account/login and then submit a completed online application and fees.

Reaccreditation Survey

Most accreditations are valid for up to three years. Your facility’s primary contact will receive a letter and email notifications about renewing your accreditation beginning approximately five months prior to your expiration date. However, ultimately it is your responsibility to submit your reaccreditation application on time. Reaccreditation applications are due no later than four months prior to your expiration date. If you submit your application late or place it on hold after submission, we cannot guarantee that the onsite survey will take place before your expiration date. The reaccreditation survey will be conducted in a manner similar to your initial survey; the surveyor will also review any previous deficiencies and evaluate your corrections. In order to be assigned a reaccreditation survey, you must submit a completed renewal application and all fees as well as be current with your facility’s annual fees.

Resurvey

Additional surveys may be required when there are significant changes such as a location move, change of ownership or addition to your facility’s scope of services. Resurveys are also required if we are unable to conduct an initial or reaccreditation survey due to unavailability at your facility or if the surveyor is denied access. To begin the resurvey process, you must submit an online application and fees.

Verification Survey

Verification surveys allow ABC to confirm various elements associated with your facility. Verification surveys are most often used to confirm that changes documented in your Corrective Action Plan (CAP) have been implemented. We will inform you in writing if we require a verification survey. You are responsible for the fees associated with a verification survey.

Quality Control Survey

We reserve the right to randomly visit any ABC accredited facility to conduct a quality control survey. We use these surveys to determine consistency among ABC accredited locations and to evaluate surveyor performance. Additionally, we reserve the right to conduct a quality control survey to determine ongoing compliance with the ABC Mastectomy Standards. These surveys are random and unannounced and may be initiated in response to consumer or professional complaints. We do not charge for these surveys.

Surveyors

Surveys are conducted by either a single surveyor or a team of surveyors. On occasion, we will send a surveyor apprentice as part of the survey team, at no additional charge to you. All surveyors and surveyor apprentices have a photo identification badge issued by ABC. Surveyors are assigned based on the programs indicated on your application.

Once your facility’s survey has been picked up by a surveyor, you will receive an email with your surveyor’s name. All ABC surveyors/ apprentices must disclose any potential conflict of interest with the applicant/facility to us before they are assigned to conduct the survey. If you have a conflict of interest with your assigned surveyor, please email accreditation@abcop.org with your name, facility’s contact information, and reason within five days of receiving your assigned surveyor email. Requests made after the five days will be denied. The following constitute as valid conflict of interest:

• The surveyor has provided consulting services or accreditation guidance of any kind to your facility.
• The surveyor has a personal relationship with owner, shareholder, or other individual working at the facility.
• The surveyor enters into employment or contract with the facility.
• The surveyor was employed or contracted or currently employed or contracted with a competing business in your local area.

Surveyors/apprentices with a confirmed conflict are not assigned that survey.

Your surveyor is not available to you after your onsite survey and we cannot provide you a surveyor’s personal contact information. ABC staff is available to you for any questions you might have. Simply call or email us at accreditation@abcop.org.

About Our Surveyors:

Background

ABC surveyors have the necessary education and training to form a solid foundation for program evaluation. The amount and kind of education and training depends upon the type and level of program to be evaluated.

Site Surveyor Training

Our surveyors receive formal, organized training through workshops conducted by experienced evaluators representing numerous aspects of the provision of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). In addition, we have developed training materials on the ABC Accreditation Standards, their structure and the relationship between ABC and the Centers for Medicare and Medicaid Services (CMS).

Approach

ABC surveyors demonstrate maturity, objectivity, diplomacy and dedication. They project an image of professionalism in both behavior and appearance. In addition, our surveyors appreciate the confidential nature of the task and understand the need for self-initiative, a cooperative attitude, an analytic approach to the task and the necessary degrees of flexibility.

Knowledge

Our surveyors are knowledgeable in the disciplines in which we accredit and of the entire accrediting process. They have sufficient general and specific experience to be able to exercise appropriate judgment. In addition, our surveyors thoroughly understand the standards as well as what constitutes deviation from or noncompliance with those standards. It is imperative that surveyors be very familiar with the content of your application and all related materials provided to them prior to the site visit.

Skills

Our surveyors are skilled in interviewing, interpersonal communications, self-expression, note-taking and maintaining objectivity. Through experience and education, surveyors have developed capacities for deductive reasoning and logical analysis. They are skilled in writing and accurate in recall.