Accreditation Decision Process

After the site visit is completed, the AAPSF Accreditation Committee will review 1he survey report, surveyor recommendations and any other relevant information and make a decision regarding accreditation. The committee carefully reviews this information and any other relevant documentary evidence before making its decision. A DECISION BY THE ACCREDITATION COMMITTEE REGARDING ACCREDITATION OF A FACILITY IS FINAL_ (see #2, #3, and #S below)

1. Duration of Accreditation - The AAPSF awards an organization accreditation for three years when it determines that the facility is in substantial compliance with the standards and there are no reservations about the accuracy of the survey findings or the organization's commitment to continue providing high-quality care and services. For facilities that have been in operation less than six months, the accreditation award may include a contingency for a follow-up visit approximately one year later.

The AAPSF may award a facility accreditation of less than 3 years when it concludes that the organization is in substantial compliance with the standards but either the organization's compliance appears to be not in place at the time of the site visit or not well established or the organization's commitment to one or more of the standards appears inadequate.

An accredited organization may be resurveyed at any time at the discretion of the AAPSF. No fee shall be charged to the facility when such a resurvey is initialed by the AAPSF. If an accredited organization is resurveyed and is judged not to be in substantial compliance with the standards, its accreditation may be revoked.

2. Deferred Accreditation Decision - The AAPSF may defer an accreditation when it concludes that the facility is in LESS THAN substantial compliance with one or more standards and demonstrates the commitment and capability to correct the identified deficiencies within six months. In such cases, the facility may request another on-site survey without paying an additional application fee. This request must be made within six months of notification of the deferred accreditation decision. The on-site survey will be conducted at the prevailing fee without the need of an additional application or application fee. The organization may elect to follow the procedures outlined in the "Appeal Mechanism".

An organization whose accreditation decision is deferred and does not request an on-site survey within six months of notification of deferral will be deemed non-accredited.

3. Denial of Accreditation - The AAPSF denies accreditation to an organization when it concludes that the organization is NOT IN substantia1 compliance with more than one of the standards. An organization that is not granted accreditation or that has had its accreditation revoked may reapply for resurvey any time following the decision. It may also elect to follow the procedures outlined in the "Appeal Mechanism",

4. Notification of Decision - The AAPSF notifies an organization of the accreditation decision by mail as soon as possible after the decision is made. Copies of the survey report are sent to the head of the facility and the Chief Administrative Officer.

5. Appeal Mechanism - If the decision of the Accreditation Committee is either to defer or to deny accreditation, the organization has the right to the following steps of appeal:

a. The organization shall submit a written request to the Accreditation Committee of AAPSF for an appeals hearing. The organization may choose to either appear in person and/or submit written documentation to substantiate their appeal. In either case, the request for appeal must be received in writing no later than twentyone (21) days after receipt of the original decision. The Accreditation Committee shall consider the appeal and render a decision within fourteen (14) days.

b. If the decision of the Accreditation Committee confirms the original action to either defer or deny accreditation the organization has the right to appeal to AAPSF whose responsibility it shall be to convene the Appeals and Controls Committee. This request for appeal must be received in writing within fourteen (l4) days of the Accreditation Committee's decision. The Appeals and Controls Committee shall consider the appeal request and render a decision within fourteen (l4) days, and this decision shall be binding and final upon the organization.


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