Accreditation Survey Procedures

The purpose of the AAPSF accreditation survey is to assess the extent of the facility's compliance with the applicable standards in this manual. Although no organization can be expected to achieve total compliance with ever standard, the AAPSF does expect substantial compliance with the APPLICABLE standards. The extent of compliance is assessed through at least one of the following means:

1. Documentary evidence (documentation and/or evidence provided in writing);
2. Answers to detailed questions concerning documentation;
3. On-site observations and interviews by surveyors.

In the event the surveyor finds that some part of the facility's operations adversely affects patient health and safety, such findings may be considered to negatively affect the accreditation decision even if the standards in this manual do not specifically cover those operations.

The survey is to be conducted in such a manner so as to enable the surveyors to gather information with minimal disruption of the daily activities of the organization. Organizations will be asked in advance to have specific documents and other information available to the surveyors. They may also be asked to submit other documents directly to the AAPSF. Surveyors may also ask to see additional materials and may request additional information during the on-site survey.

At the conclusion of the site visit, the surveyors hold a summation conference in which they present their findings to representatives of the facility for discussion and clarification. Various members of the facility's staff are encouraged to take part in this conference. The reports and recommendations of the survey team are then submitted to the AAPSF Accreditation Committee for review and decision as described later in the section titled "Accreditation Decision, Notification and Appeal Mechanism".


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