Do Your Part for a Successful Survey

Your survey for ACHC Behavioral Health 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 the survey, your Surveyor will review numerous documents and other items that support compliance with ACHC Standards and applicable state regulations.

Your organization 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 the required reports at the opening conference: current service recipient census, schedule of visits, discharge/transfer census for the past 12 months, and personnel list (employee and contracted staff).
• Provide a brief tour of the facility, emphasizing the following:
  • Service recipient record storage/safeguarding.
  • Confidentiality maintenance of Protected Health Information (PHI).
  • Supply closet/area.
  • Medication storage, 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 plan, performance improvement (PI) plan, and any requested administrative documents.
• Provide the service recipient 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.
• Arrange and obtain verbal consent from the service recipients for interviews.
• Provide all 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.