Accreditation Programs

AAHHS offers accreditation for acute care and critical access hospitals. The programs parallel those of HFAP which means that a hospital can choose to use a cost-effective accreditation survey as a consultative step in preparing for state inspection.

For independent ASCs and outpatient care facilities, accreditation is currently offered through the well-established HFAP programs. For hospitals that provide outpatient services through an affiliated ASC (under a separate CCN), AAHHS-HFAP offers the opportunity for concurrent surveys. Learn more about HFAP programs here.

AAHHS Policies

Hospitals are considered for survey by AAHHS on an individual basis. A hospital is eligible for an accreditation survey by AAHHS if the hospital meets all of the following criteria. The hospital shall:

  • Be located in the United States or its territories, operated by the U.S. government or under the charter of the U.S. Congress.
  • Meet all state and local licensing requirements.
  • Provide professional care and hospital service on an ongoing 24-hour basis.
  • Meet the definition of a hospital under the Social Security Act §1861.

The Standards match those of HFAP and are founded in the CMS Conditions of Participation for hospitals and critical access hospitals.

Email us for access to the current AAHHS manual for Hospitals.
Email us for access to the current AAHHS manual for Critical Access Hospitals.

Accreditation and Survey Fees

The Accreditation Fee is determined using the fee calculation form that you may request by email and from information in the hospital’s Application for Survey and supporting documentation. Factors considered in determining accreditation fee include the size, type, and range of services provided by the hospital.

The Survey Fee is billed following the on-site survey and includes an administrative fee, surveyor honoraria and expenses.

If an intracycle survey is required, the hospital will be invoiced an additional survey fee only.

Hospital surveys for CMS deemed status are unannounced and conducted on a triennial cycle.

“Mock surveys” intended for consultation in preparation for state inspection or surveys for accreditation only (without CMS reporting) are scheduled in cooperation with the hospital being surveyed.

A request for cancellation of a scheduled survey and a refund must be received by the AAHHS-HFAP office in writing on company letterhead from the organization (emailed PDF is acceptable) making the request.

For cancellation or postponement of an survey due to any circumstance, the organization will be responsible for all direct and indirect costs associated with the cancelled survey, including, at minimum, an administrative fee and any non-refundable costs incurred for surveyor transportation and lodging according to the following schedule:

If an organization cancels 30 calendar days or more before the scheduled start date of the survey, the Accreditation Fee will be refunded, less a $500 administrative fee and any nonrefundable costs including, but not limited to, the cost of surveyor transportation and lodging.

If the organization cancels its scheduled survey 21 to 29 calendar days before the scheduled start date of the survey, the Accreditation Fee will be refunded, less a $500 administrative fee, surveyor honoraria of $300 per surveyor per scheduled survey day, and any additional direct and indirect nonrefundable costs including, but not limited to, the cost of surveyor transportation and lodging

If the organization cancels its survey fewer than 20 calendar days before the start of the scheduled start date of the survey, no refunds or credits will be given.

If an organization cancels or postpones a scheduled survey more than once per accreditation/certification cycle, additional fees will be assessed at the discretion of HFAP, and the fees must be paid prior to scheduling the next survey. Accreditation/certification decisions are not released to an organization with unpaid survey fees.

Following an accreditation survey, a hospital may be awarded a three-year term of accreditation with or without intra-cycle survey activity or be denied accreditation.

AAHHS denies accreditation to a hospital when it concludes that the hospital is not in substantial compliance with the AAHHS Standards and/or AAHHS policies or procedures as follows:

  1. A denial of accreditation may be made when, during an initial survey, a facility fails to demonstrate compliance with one or more CMS Conditions of Participation.
  2. Revocation of accreditation may occur when the provider or supplier:
    1. is substantially noncompliant with accreditation standards and has not corrected its deficient practices within the timeframe specified by AAHHS-HFAP.
    2. fails to pay accreditation fees.
  3. The written notice of impending revocation of accreditation will be addressed to the president of the governing body, chief executive officer and the chief of staff of the hospital.
  4. Denial or revocation of accreditation becomes effective 30 days after action by the AAHHS Board of Directors if there is no appeal by the hospital. This enables health care facilities to maintain accreditation for 30 days while applying for state certification. However, the AAHHS Board of Directors reserves the right to forego the 30-day period if it believes that the facility has failed to provide a safe environment for care or that the facility has failed to mitigate any situation that could pose an immediate threat to patient safety.
  5. AAHHS may choose to revoke a facility’s accreditation for the following reasons:
    1. Failure to follow AAHHS-HFAP policy and procedure.
    2. Failure to meet accreditation requirements.
    3. Failure to meet AAHHS-HFAP standards.
    4. Failure to meet Medicare requirements (substantial non-compliance with CMS conditions of participation).
    5. Non-payment of fees associated with accreditation in a timely manner.
    6. Requirements not met.
    7. Falsification of information submitted during the application process or during survey.
    8. Failure to permit the performance of a survey.
    9. Failure to correct deficiencies related to an immediate jeopardy situation.
    10. Failure to submit a Plan of Correction for noncompliance identified during survey.
    11. Inability to sustain compliance with standards after a second focused resurvey.
    12. Alleged criminal activity.
  1. A facility may appeal the action to revoke accreditation to the Appeals Committee. This request must be in writing and must be filed within thirty (30) calendar days following receipt of the decision to revoke accreditation status. The Appeals Committee is convened by teleconference within ten (10) business days of receiving notification from the facility that it wishes to appeal the decision. The facility may provide additional materials to the Appeals Committee for its consideration but may not take part in the teleconference.
  2. AAHHS will notify the facility in writing of the action taken by the Appeals Committee within three (3) business days of the teleconference. This action is final.

Accredited hospitals must notify AAHHS in writing within 15 calendar days of any significant organizational, operational, or financial changes including, but not limited to:

  • Merger or acquisition
  • Change in controlling interest/ownership
  • Consolidation
  • Name change
  • Hospital relocation to another physical location
  • Additional services or locations
  • Major renovations
  • Expansion
  • Patient death, loss of limb, or other major permanent loss of function associated with care provided
  • Breach of infection prevention program
  • Any state-mandated reporting
  • Any interruption in delivery of health care service that exceeds 30 calendar days.
  • Adverse publicity or adverse media coverage related to the hospital or its providers.
  • Changes in state license or other applicable license, (e.g., business license), federal certification, or qualifying status.
  • Bankruptcy or other significant change in the financial viability of the hospital.
  • Any governmental investigation, including local, state, or federal authorities involving, directly or indirectly, the hospital or any of its officers, administrators, medical staff, or other staff, in their role within the hospital.
  • Criminal indictment, guilty plea or verdict in a criminal proceeding (other than a traffic violation) involving, directly or indirectly, the hospital or any of its officers, administrators, medical staff, or other staff in their role within the hospital.

A hospital’s duty to provide this information continues throughout the entire accreditation process and term. In the event that the hospital is exercising its right to appeal, the hospital must notify AAHHS in writing immediately of any such changes. Failure to notify AAHHS in writing may result in an immediate revocation of accreditation, or termination of the right to appeal.

Accreditation is not automatically maintained when an accredited hospital undergoes significant changes as described above. AAHHS will determine whether the current accreditation term will be maintained and establish the conditions of such.