Your on-site survey for ACHC Sleep 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 organization is responsible for supporting the Surveyor to ensure the process goes smoothly. To assist your Surveyor, your team 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 following required documents at the opening conference:
  • Policy and procedure manual and employee handbook.
  • Any subcontractor agreements and business associate agreements.
  • Insurance docs, licenses.
  • Complaint file(s)/log.
  • Incident/variance reports.
  • Performance improvement (PI) records since your last survey. (Does not apply to initial surveys.)
  • Current organizational chart.
  • List of current employees with their job titles and start dates.
  • Admission packet for new patients.
  • Previous survey/inspection results (NSC, fire department, FDA, etc.), if applicable.
  • Annual fire and disaster drills, backup power tests, and TB prevalence rate logs.
  • Binder of safety data sheets (SDS).
  • Records on equipment cleaning, maintenance, and repairs/recalls.
• Conduct a brief tour of your sleep facility.
• Provide copies of your emergency preparedness plan, PI plan, and any requested administrative documents.
• Provide the patient records and personnel files selected randomly by the Surveyor. A computer must be supplied to the Surveyor to access any electronic records in a “read-only” format.

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 briefly discuss survey findings. ACHC will send you an official Summary of Findings document within 12 business days from the last day of your survey.

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. 458.