Your survey for ACHC Renal Dialysis Accreditation is a collaborative effort between the Surveyor and your organization. Each is responsible for performing certain duties to collectively ensure a successful survey experience.

On the day of your survey, the Surveyor will review numerous documents and other items that support compliance with ACHC Standards and applicable state regulations.

Your facility is responsible for supporting the Surveyor to ensure the process goes smoothly. To assist your Surveyor, your organization should do the following:

• Check the Surveyor’s photo ID badge upon arrival.
• Designate a workspace for the Surveyor.
• Appoint a survey liaison.
• Provide the Surveyor with all required reports/documents/logs/items within three hours after the opening conference. All of the following must be provided: current patient census (separated by modality), patient treatment schedule, list of key personnel, staff schedule for the past two weeks, and any additional reports that the Surveyor requests. (Download the “Items Needed for Survey” document from ACHC Customer Central for a complete list of required reports/documents/logs/items.)
• Provide a brief tour of the facility, emphasizing the following:
  • Treatment area (in-center and home training), medication room/area, lab, clean supply area/storage, etc.
  • Medical record storage/safeguarding [maintenance of Protected Health Information (PHI)].
  • Water room, warehouse, reuse room (if applicable).
  • Biohazard waste storage/handling.
  • Required posters and signage.
  • Fire safety equipment and signage.
• Ensure your policies and procedures are available for review and/or reference.
• Provide copies of your organization’s emergency preparedness and QAPI plans, tracking data on the COVID-19 vaccination status of facility personnel and contracted individuals, and any requested administrative documents.
• Provide the medical charts and personnel files selected by the Surveyor. A computer must be supplied to the Surveyor to access any electronic records in a “read-only” format.
• Provide all direct care service contracts and agreements.

If you have questions about items requested or deficiencies found, ACHC encourages you to seek clarification from your Surveyor while they are still on site.

During the survey closing conference, your Surveyor will review the preliminary summary of findings. The Surveyor does not make an accreditation determination. After your survey, the Surveyor will submit information collected for processing.

Here to Help

ACHC is more than an accreditor. We are your partner. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242, ext. 457.