Behavioral Health Accreditation Process
1. Create a Customer Central Account Your first step in the accreditation process is to create your Customer Central Account, where you will have access to all of the tools needed to achieve and maintain ACHC accreditation. Once you have registered your account, you will have the ability to select ACHC standards, complete an online application, and access all of ACHC’s accreditation resources. Your organization will also receive a personal Account Advisor who will serve as your consistent point of contact throughout the entire process.
2. Download ACHC Standards
The next step in the process is to download the ACHC standards relevant to the programs and services you provide. Your Customer Central account will provide you access to preview and purchase ACHC standards. By purchasing, you will gain unlimited access to ACHC standards.
3. Submit the Required Documents
ACHC requires the following five items to be completed before scheduling your survey:
- Online Application
The online application is found on your Customer Central account. Here, you have the ability to complete the entire application process in one, easy-to-use interface.
Quickly and securely submit your accreditation deposit through Customer Central.
- Accreditation Agreement
Review and return your signed Accreditation Agreement (contract) to ACHC.
- Payment Method
Schedule your payments by selecting the payment method of choice for the remaining accreditation balance.
- Preliminary Evidence Report (PER)
The PER allows your organization to submit select documentation to ACHC for review prior to the accreditation survey. This step provides supporting evidence to demonstrate your organization’s understanding of, and compliance with, ACHC standards.
4. Scheduling the Survey
Surveys are scheduled once the Accreditation Agreement (contract) is signed and the PER is submitted. Please note that all surveys are unannounced (with the exception of initial licensure surveys for Home Health agencies). You will have the opportunity to select 10 blackout dates on your application. ACHC will not conduct surveys on your blackout dates or major holidays (as defined in the ACHC Policies and Procedures). Surveyors are selected based on the services your organization provides, and are expertly qualified through professional experience and continuous ACHC training.
5. On-Site Survey
ACHC will notify customers by phone within one or two hours on the day of the survey with identification information about their ACHC Surveyor. The on-site survey consists of the following:
- A. Opening Conference
- B. Tour of the Organization
- C. Data Collection
- • Personnel record review
- • Patient record review
- • Financial/billing records
- • Service contracts
- • Risk management
- • Performance Improvement (PI) activities
- • Policies and Procedures (P&P)
- • On-site observations
- • Personnel and patient interviews
D. Closing Conference
6. Post Survey
Following the conclusion of the on-site survey, the ACHC Surveyor submits all of the data collected to the organization’s Account Advisor for processing. The information is entered into an electronic tool that provides data for determining the decision.
Preparing the Summary of Findings
The Summary of Findings (SOF) is prepared, detailing all ACHC standards and corresponding Medicare Conditions of Participation (CoPs) that were marked as a deficiency during the on-site survey. Each ACHC standard marked as a deficiency contains an “Action Required” statement. This assists the organization in preparing a Plan of Correction (POC) to meet the ACHC requirements. Surveyors may include any best practice suggestions in their summary as additional education. These best practice suggestions are not mandatory for the organization, but are recommendations for improvement.
Accreditation Review Committee
All SOFs are analyzed by the appropriate Clinical Manager or designee, and are evaluated by the Accreditation Review Committee to ensure accuracy before a final decision is rendered. The Accreditation Review Committee consists of a minimum of three experts.
7. Accreditation Decisions
There are four possible outcomes for an accreditation decision.
There are no deficiencies found. The organization is compliant with all ACHC standards. Accreditation is granted for three years.
The organization is found to be faulty in one or more standards. The organization submits a Plan of Correction (POC) for all standards that are deficient, and the POC will be reviewed by the Accreditation Review Committee. When a POC is approved, ACHC can issue accreditation to the organization.
The organization is found to be deficient in a number of ACHC standards and/or at least one Medicare Condition of Participation (CoP). The organization submits a Plan of Correction (POC) for all standards that are deficient, and the POC will be reviewed by the Accreditation Review Committee. ACHC will schedule a Dependent survey at the company's expense. Based on the findings of the Dependent survey, a final decision will be made by the Accreditation Review Committee.
The number, scope, and/or severity of deficiencies demonstrate substantial noncompliance with standards. If accreditation is denied, the company has the opportunity to re-apply for Accreditation at any time they believe they are ready for survey.
8. Accreditation Status
Once accreditation is achieved, the organization’s Account Advisor will send an accreditation approval letter and an accreditation certificate by mail. The provider will also have access to the certificate and letter on their Customer Central website. Additionally, the ACHC marketing material and branding standards are available on Customer Central.
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