Related Entities

Organizations with Multiple Service Locations

For multi-site organizations seeking accreditation, AAAHC will determine which service sites will be visited during any survey.

If an organization indicates that a service location should not be reviewed, this site will not be eligible for accreditation and will not be listed on the AAAHC Certificate of Accreditation.

ASCs with multiple service locations that have unique CMS Certification Numbers (CCN) must apply for and be surveyed as separate, independent ASCs.

An AAAHC/Medicare deemed status survey may only be requested by a currently Medicare certified ASC or one that is seeking Medicare certification. Any other associated entity must request accreditation separately from the ASC seeking AAAHC/Medicare deemed status.  

Inclusion of Related Patient Care Entity or Service

Although in general the AAAHC surveys and accredits a single legal entity, it will review a sub-unit of an eligible legal entity, if requested, when the sub-unit exhibits autonomous characteristics and demonstrates the capability to meet the AAAHC standards on its own.The accreditation site survey will be limited to a review of the autonomous sub-unit.

When the applicant organization is a sub-unit of a legal entity and does not exhibit autonomous characteristics, the accreditation site survey will include a comprehensive review of all aspects of the organizational legal entity. In addition, when the applicant organization is a separately organized legal entity, but does not exhibit autonomous characteristics from another legally related entity, the accreditation site survey will include a comprehensive review of all aspects of the related legal entity. However, any accreditation decision conferred will apply solely to the applicant seeking accreditation even though other entities were included in the survey review process.

Organizational integration exists when the applicant organization’s governing body, either directly or ultimately, controls the budgetary and resource allocation decisions for the related entity or service. Where separate corporate entities are involved, organizational integration also exists when there is greater than 50 percent of the same governing body membership on the board of the applicant organization and the board of the other entity.

Functional integration exists when the entity meets four of the following criteria, including either

criterion 1, 2, or 3:

1. The applicant organization occupies physically connected floor space and/or a geographic

location with the related entity or service such that the related entity or service is represented

or reasonably appears to the public as being part of the applicant organization.

2. There is a common organized medical or professional staff for the applicant organization

and the related entity.

3. The applicant organization’s human resources function is responsible for all staffing of the

related entity or service and development and implementation of established personnel activities.

4. The applicant organization manages all operations of the related entity or service, i.e.,

the related entity has little or no management authority or autonomy independent of the

applicant organization.

5. The applicant organization applies its quality improvement program to the related entity or

service and has authority to implement actions intended to improve the performance at the

related entity or service.

6. The applicant organization bills for services provided by the related entity or service under

the name of the applicant organization.

7. The applicant organization’s policies and procedures are applicable to the related entity

or service, with few or no exceptions.

8. The related service or entity’s patient records are integrated into the applicant organization’s

record system (or vice versa).