Nearly all organizations surveyed for accreditation are cited for deficiencies. To address deficiencies, a sleep lab or center must develop an effective Plan of Correction (POC) and submit it to ACHC before a final accreditation status is determined. This is the final step in the accreditation survey process.

After your survey, you will receive an accreditation decision letter, survey Summary of Findings (SOF), and POC form from your Account Advisor within 12 business days from the last day of your survey for ACHC Sleep Accreditation.

The SOF will list deficiencies identified during the survey and identify requirements for compliance with ACHC Standards. To address these findings, a POC form must be completed that details your corrective steps and monitoring activities. Approval of your POC must be received from ACHC.

The completed POC form must be submitted to ACHC within 30 calendar days from the date of the Summary of Findings.

POC Requirements

For your POC to be approved, your form must contain specific information under the following headings:

• Plan of Correction. In this column, provide details of the specific action steps your organization has taken or will take to address the identified survey deficiencies.
  • Typically, the POC includes corrective actions you have implemented or will implement, such as re-educating your staff and/or revising a policy and procedure. You must describe the specific actions taken or will be taken to ensure deficient practices are resolved.
    • For example, if a deficiency was due to staff failing to follow organizational policy, the action step required for compliance would be to re-educate staff.
    • If the deficiency was a result of an insufficient policy, the action step required for compliance would be to revise the policy and educate staff on the revised policy.
• Date of Compliance. This column notes the date the corrective action steps occurred or will occur.
• Title. In this column, provide the title, not the name, of the individual responsible for ensuring corrective actions have been or will be implemented.
• Process to Prevent Recurrence. In this column, describe your plan to prevent falling out of compliance with this standard again. This will be an action different from what was noted in the Plan of Correction column. Also provide details on the ongoing monitoring process to ensure that actions taken or will be taken are effective at correcting deficiencies. If a standard on the SOF indicates it was corrected during the survey, you must still enter a Process to Prevent Recurrence on the POC form.
  • There is a two-step monitoring process for deficiencies related to medical record reviews. For corrective actions that require medical record audits:
    • First, include the percentage of medical records to be audited, the frequency of the audits, and the target thresholds. Ten records must be monitored on at least a monthly basis until thresholds are met.
    • Second, the monitoring step must include actions for continued compliance once target thresholds are met. This usually involves reducing the percentage of medical records to be audited and/or reducing the frequency of audits.
      • For example, the continued monitoring step could be to audit 10% of active medical records on a quarterly basis to ensure the desired threshold is maintained.
  • For an insufficient policy, monitoring should include an annual policy review to ensure compliance.
    • For example, if the deficiencies were related to the patient rights and responsibilities statement and applicable policy, the corrective actions would be to revise the policy and revise the patient rights and responsibilities statement. To prevent recurrence, review the policy and statement annually.

Next Steps

After you submit your POC to ACHC, an ACHC clinical specialist will review your information and determine if the action steps and the monitoring process to prevent recurrence will resolve the deficient practice(s) and ensure ongoing compliance.

If it is determined that the action steps and/or the continued monitoring will resolve the deficient practice(s), a “Yes” will be documented in the POC Compliant column on your POC form. If it is determined that the action steps or continued monitoring will not resolve the deficient practice(s), a “No” will be entered on the form. The ACHC clinical specialist will provide an explanation of ”No” decisions in the Comments section of the form.

You will be notified about the approval status of your POC. If your POC is not approved, you will be asked to revise your POC.

Failure to submit an acceptable POC within the required time frame may result in a change of accreditation status to Denial of Accreditation.

Evidence

For your POC, you only need to submit evidence for standards listed on the SOF under the category labeled **Evidence Required on POC**. Your POC form will also indicate, under the standard number, if evidence is required. No other evidence is required unless specifically requested in the SOF or by ACHC. All required evidence should be submitted with your POC form.

Final Status

Your final accreditation status will be determined upon review of your submitted POC and supporting documentation. All fees must be current before ACHC sends you final notification of your accreditation status.

Here to Help

ACHC is your partner in accreditation. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242, ext. 458.