Quality Accreditation + Quality Time = Quality Care

Quality Accreditation + Quality Time = Quality Care

By: Teresa Harbour, SVP Accreditation | Fran Petrella, SVP Government Affairs and Corporate Accounts | Jennifer Kennedy, VP Quality

CHAP has always placed patient care as our number one priority. Our mission is to advance the highest quality of home and community-based care.

Because CHAP solely focuses on home and community-based organizations, every initiative is to improve care/services provided by the organizations we accredit. Today, an onsite visit is the best way to evaluate care delivery. The contact between the surveyor and the provider is an irreplaceable hands-on experience that cannot yet be reproduced virtually without compromising value and results.

CHAP not only assesses quality care delivery and compliance with federal regulations and CHAP standards, we also guide and educate providers related to the rationale for the regulations and standards. CHAP receives regular post-survey feedback from providers stating the benefit of this approach.

Your site visit focuses on care delivery, including record reviews and home visits to observe agency staff providing care. Our surveyors spend additional time with agencies to ensure a thorough review of patient records, home visits, personnel records, and other documents. During home visits, we not only observe care delivery, we also talk with patients and families about the delivery of care and their involvement in the plan of care. We review the agency’s performance improvement projects and provide education to agencies to support positive patient outcomes.

CHAP takes our responsibility for assessing care delivery and ensuring adherence to regulations and our standards of excellence very seriously. It is our obligation and responsibility to take the time to assess all aspects of a provider’s operation to ensure patients receive safe, quality care.


Defining the Quality of a Survey

CHAP has various levels of post-onsite survey review to ensure the survey complies with regulations and/or CHAP Standards of Excellence. These areas include:

  • Patient-centered care
  • Safe care delivery
  • Sustainable organizational structure

Our Directors of Accreditation provide a second-level review, and CHAP’s Board of Review, our third level of review, determines accreditation. The accreditation decision is based upon the scope and severity of deficiencies and the plan of correction.

Regulations and/or standards of practice are the framework a provider follows to furnish high-quality care to every patient. Identifying deficiencies with regulations and/or the CHAP Standards of Excellence is the mechanism for the organization to correct and improve its performance. Only by identifying gaps can performance improve. It is crucial to identify deficiencies so agencies can make improvements. Sometimes these improvements are minor but could adversely affect patient care, and immediate interventions are needed.

A survey that is not thorough and less than comprehensive may include incomplete record reviews, lack of evaluation of care delivery, limited personnel reviews to evaluate staff competency, and missed opportunities to identify areas for performance improvement. Non-compliance with regulations and/or standards of practice and unsafe care provision could result in negative patient outcomes coupled with legal and financial penalties.


An Unmatched Experience to Facilitate Provider Success

By going onsite, agencies can demonstrate care delivery through direct observation and allow our surveyors to provide feedback, education, and support to improve care delivery. The onsite survey also allows for valuable input on performance improvement opportunities.

An onsite visit is necessary to validate the implementation of regulations and requirements. For example, validate office location, including access to the public, the ability to secure patient information, staff requirements, and observe the delivery of care to ensure safe, quality care.

All our surveyors are bachelor’s prepared RNs with years of experience in home health and hospice. They have all held leadership positions within organizations, so they can evaluate agencies from the governing board level to the delivery of care. All surveyors are employees of CHAP with an average tenure of 4 years and 9 months, contributing to their consistency, expertise and knowledge. As technology and virtual options evolve, CHAP will continue to innovate and be recognized as an essential partner for facilitating exceptional home and community-based care.


“CHAP standards align with Medicare Conditions of Participation and regulatory framework to support Compassus at the enterprise level, the community level and for every clinician with confidence that care delivery is meeting the highest standards. The CHAP standards framework provides guidance through documentation, policies, and the format of delivering care. Compassus has been tracking our survey outcomes over the past five years, providing health care system partners with demonstrable evidence of survey outcomes and assurance that improvement occurs when needed. We utilize the standards to go beyond compliance and target ways to improve quality and care delivery.”

Jen Hale, Compassus


We do not rush through the survey process; we want to ensure adequate time is provided for our surveyors to complete a quality review of the agency. In addition, the provider has time to leverage the site visitors’ knowledge and expertise as well as the thorough, educative, and collaborative process we follow to facilitate the success of the provider.

Our customer satisfaction survey responses generally commend the positive, collaborative site visit experience our site visitors afford the providers.

CHAP has continued to be an innovator in the accreditation industry for the past 57 years. We take pride in the value of work we perform, and holding steady to our convictions without compromising standards and quality of care.