Patient Care Facility Accreditation Guide

Full Approval

ABC Facility Accreditation is awarded when there is full compliance with all applicable standards. Facilities with full approval will receive an electronic decision, survey report, and certificate, with copies mailed to the primary facility.

Corrective Action Plan (CAP) Decisions

If a facility has any deficiency, the facility may be given the opportunity to submit a Corrective Action Plan (CAP). A CAP demonstrates compliance with the standard(s) in question. CAPs are reviewed on a case-by-case basis, and submission does not guarantee accreditation.

Failure to submit an approved CAP within the allotted time results in revocation of existing accreditation or denial of accreditation. No fees are associated with CAP submission.

      This icon indicates each of the standards that, if marked P or N, will require a CAP.

Fail with a Corrective Action Plan Requirement

If the overall score is not within the passing range, the facility may be given the opportunity to submit a CAP. During the review period, your facility is not considered accredited.

Corrective Action Plan Timeline

CAPS are due within 14 days of the decision email date -failure to submit a CAP by the deadline results in denial or revocation. CAP reviews take approximately 14 days.

Incomplete Corrective Action Plans

If a CAP does not adequately demonstrate compliance, ABC may request additional information with a specified timeframe. 

Supporting Corrective Action Documentation and Format

A 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, de-identified patient notes, pertinent updated policies, and meeting minutes. Entire Policy and Procedure manuals are not accepted as a CAP unless directly relevant to the surveyor's comment or standard.

Denial

Common causes for denial include lack of access, facility closure/unavailability, or CAPs that fail to address identified issues or that are not submitted by the deadline.  A denied facility must reapply and be resurveyed.

Accreditation Effective Dates

For new and renewing facilities, effective dates may be the first day following a passing initial survey, the date a reaccreditation application was received when the reaccreditation survey is passed, or the date a qualifying CAP was received.  Accreditation for facilities requesting add-on services may be effective on the application receipt date if the add-on survey is passed.