Mastectomy Facility Accreditation Guide

Accreditation requires that you continue to comply with the ABC Standards, abide by all policies and procedures and submit your annual fees on time. Failure to fulfill any of these requirements may result in the revocation of your facility’s accreditation.

Facilities must notify ABC of any and all changes within 30 days of the effective date of change.

Such changes include:

Moving a Location

You are required to reapply for your facility should you change addresses as ABC is required to visit your new address. ABC cannot update our facility records without the completion of the accreditation application and associated fees with the updated address. You will then be scheduled for an onsite survey at your new location.

Adding a Location

You are required to apply for accreditation for all operational patient care sites and related administrative and warehouse locations. Administrative, warehouse and patient care sites that are within 100 miles driving distance of your primary location and under the same Tax ID must apply as affiliate locations (not to exceed four affiliates per primary); those outside of 100 miles or that do not meet the affiliate definition must apply as a primary location.

Any affiliate or related office that opens after the primary location has been granted accreditation cannot advertise or otherwise consider itself an accredited patient care center until you have applied for and been granted accreditation status by ABC. You must submit a new application, including all appropriate fees, upon the opening/acquisition/merger of an affiliate location. Once your application has been approved, ABC will determine if the location is eligible for a 90-day accreditation, with full accreditation contingent on passing your onsite survey with no significant compliance issues. If approved for full accreditation, this accreditation will be valid for the length of your primary location’s current accreditation.

Changing Corporate Structure

If you are changing your corporate structure, you must submit written details of the change, effective date, legal documentation (i.e. new business license, Articles of Incorporation) and ownership information to ABC. If you are changing ownership in addition to the corporate structure, please see the Ownership Changes section.

Discontinuing a Service

You must notify ABC in writing if you discontinue providing mastectomy patient care services. If you add the service at a later date, you must reapply with all applicable fees.

Closing or Selling Your Facility

You must notify ABC in writing if you close or sell your facility; notification must be sent within 30 days of the sale or closure. You must also mail the original active accreditation certificate to ABC. If you reopen your facility at a later date, you must submit a new online application and all related fees. If your facility is sold, your accreditation is not transferable to another owner, and the new owner of your facility will need to reapply (see Ownership changes).

Lawsuits and Disciplinary Actions

You must notify ABC if there are pending lawsuits and/or disciplinary actions against any staff members or locations when you apply for accreditation. A detailed written statement that includes the following must be submitted with your application and fees:

• A description of the incident
• The date and where the incident occurred
• The verdict of the charge(s) that were filed against the individual
• Any penalty/sentence associated with charges
• When the sentence was, or will be, completed
• Court case summary of the incident

Copies of court documents are also required. If the documents are not available, indicate the jurisdiction in which the charge(s), conviction or plea occurred and why the documents are not available. If all the appropriate information is not provided, the processing of your application will be delayed and your application may be considered incomplete.

You must also inform ABC in writing if any legal or disciplinary action is taken against the facility or its employees at any time during the accreditation period.

Ownership Changes

Adding Owners to Existing Ownership

ABC requires that you submit a renewal application for resurvey with a detailed letter, accreditation fees and legal documentation of the changes. When completing your application, please make sure you select the option for Ownership Change. If you are adding owners to your facilities, you will maintain your current accreditation cycle while waiting for an onsite survey.

Complete Change of Ownership

ABC Accreditation is not transferrable between two different owners. A complete change in ownership requires the facility to be resurveyed. If no existing owners are remaining at the facility, the new ownership must submit an online application, application fee, and upload a letter detailing the changes as we as supporting legal documentation of the sale. ABC is authorized to issue a 90-day accreditation if your facility is accredited and in good standing under a different owner. To be issued a 90-day accreditation based on an ownership change, you must make your request in writing, along with your application, legal documentation of the sale and all fees. In order to issue a 90-day accreditation, your application must be approved and accreditation must be verified. We will approve the product categories based upon your facility’s previous accreditation and in accordance ABC’s Mastectomy Scope of Practice.

Removing an Owner from Existing Ownership

If you are removing an owner from your facility’s existing ownership, you must submit a letter detailing the change, the effective date and provide legal documentation (i.e. Transfer of Shares evidence, Articles of Incorporation). A resurvey is not required as long as an existing owner remains.

Personnel Changes

You are responsible for notifying ABC of employment status changes for all certified and licensed personnel within 30 days of the effective change date. All notifications must be made in writing. In the event that a personnel change leaves your facility without a qualifying professional, you have a maximum of six months from the last day of employment to replace the professional. Failure to do so will result in loss of accreditation for that discipline. This six-month grace period is allowed once per accreditation cycle. During this time, your facility must still operate within the ABC Scope of Practice and in accordance to state and federal laws.

Complaint Process

ABC’s Professional Discipline Committee (PDC) will investigate all complaints involving an ABC accredited facility or any accreditation applicant that appears to be out of compliance with the Accreditation Standards or Code of Professional Responsibility. You must provide ABC’s contact information to clients/patients for the purpose of reporting a complaint.

ABC will notify the appropriate regulatory authorities if an alleged complaint involves:

• Possible abuse, neglect or exploitation
• Professional misconduct
• Noncompliance with state or federal laws

You will be informed of all allegations and provided with copies of all complaint-related materials.

If a review of the complaint determines that there is immediate risk to patients, we will notify the appropriate governmental and investigative agencies. If the situation does not pose immediate risk, the complaint will be investigated in accordance with the Code of Professional Responsibility.

Depending upon the nature of the complaint, the following actions may be taken:

• ABC will follow the guidelines outlined Code of Professional Responsibility and may also:

- Request your cooperation in resolving the complaint

- Request that you respond to the complaint within an identified time frame

- Determine if you are aware of the complaint and if you have taken action

ABC will review all the information collected about the complaint, including any information gathered in a re-survey. If the investigation reveals the complaint or allegations are valid and a patient’s health, safety and welfare are at risk, accreditation may be revoked or suspended. You may appeal the committee’s decision by following the appeals process.

If the ABC Professional Discipline Committee makes the decision to revoke your accreditation, we will notify the appropriate regulatory agencies of our decision.