Find a Provider AIS Inspections Standards Customer Central
ACHC
Skip Navigation Links Home > Programs > Sleep > Sleep Lab Accreditation Process
sleep-lab

Sleep 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 Accreditation 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.

  • Deposit
    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

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

Scoring
Following the conclusion of the on-site survey, the ACHC Surveyor submits all of the data collected to the organization’s Accreditation 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.

Accredited
There are no deficiencies found. The organization is compliant with all ACHC standards. Accreditation is granted for three years.

Accreditation Pending
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.

Dependent
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.

Denied
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 Accreditation 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.

If you are seeking initial Medicare certification, ACHC will submit the appropriate paperwork to CMS with a recommendation of Deemed status to the CMS Central Office, CMS Regional Office, and the state in which the organization is located. Your Accreditation Advisor is available to answer any questions you have throughout the entire process.


free standard
sleep-lab

Sleep Lab Testimonials

Show All Testimonials
  • "Your team was very nice and offered great suggestions for improving.  I thought it was very good dialogue.  I liked the team we worked with."

    SleepMed Phoenix LLC
  • “We're very proud to be accredited with ACHC. We would recommend ACHC to anyone in the healthcare industry because of their level of service and commitment to the customer.”           

    Pro-Med Equiment and Supply, Inc
    Ahoskie, NC
  • "Our Accreditation Advisor was friendly & very attentive to our needs. She responded promptly to any requests for assistance. ACHC has realistic expectations for their hospital-based sleep labs. The process was straight forward, expectations were well defined, & the PER was easy to interpret. Surveyors were professional, open & honest as to our strengths and weaknesses & offered suggestions based on their experiences for best practices. The survey helped us to identify our strengths & weaknesses & improve processes, which will ultimately provide a better end product for our patients." 

    EMH Regional Healthcare System
  • "YEAH! I knew it was just a matter of time before these things began to happen for you & for all of us. So thankful that I met Tim, so appreciative of all the staff’s hard work, and thankful that Western Sleep has the pleasure of being among the first labs accredited by the ACHC. Yeah!"

    Mark Schultz
    Western Sleep Medicine, LLC

     

Getting Started

About ACHC

Programs

News

Resources

Contact Us

CMS Deeming Authority For: Home Health, Hospice & DMEPOS | Certified to ISO 9001:2008 | Site Map | © Accreditation Commission for Health Care, Inc.
Contact us at: customerservice@achc.org | Phone: 919-785-1214 | Fax: 919-785-3011 | Toll-Free: 855-937-2242 | www.achc.org
Terms of Use | Privacy Policy | Return Policy
139 Weston Oaks Ct. | Cary, NC 27513

facebook twitter blog youtube linkedin google plus one