Early Option Surveys (EOS) are conducted for organizations that are not accredited by the AAAHC and meet AAAHC eligibility criteria, but have been providing services for fewer than six months.

Such organizations (1) must meet laws or regulations that require accreditation before the facility can legally begin operations; or (2) are newly constructed, operational, and require accreditation for third-party reimbursement, and a six-month wait for a survey would entail financial hardship.

The organization must complete an Application for Survey and meet the following requirements before an EOS survey can be scheduled:

• Licensure or provisional licensure has been obtained from the state licensing authority; if the organization is not subject to facility licensure law, then it should provide a statement from the appropriate authority attesting to this fact. If the state requires a licensure survey, but the survey cannot be conducted until immediately prior to opening for preliminary licensure, verification of the license or licensure survey must be obtained by the AAAHC surveyors at the time of the EOS.
• The building in which patient care services will be delivered is built and ready to support patient care service delivery, as evidenced by reports of any inspections conducted by state and local fire marshals, state or local health departments or other code enforcement agencies.
• The date to begin operations has been identified.
• All governance and administrative structures, including bylaws, policies and procedures, are in place.
• Key executives are employed and medical staff have been credentialed and privileged by the governing body.
• All necessary equipment is in place and has been appropriately tested and/or calibrated with up-to-date maintenance logs in place.

After review of the completed Application for Survey and supporting documentation, the AAAHC will contact the organization to establish survey dates.

Initial accreditation surveys are conducted for:

• Organizations that are not currently accredited by the AAAHC and have been providing services for at least six (6) months before the on-site survey.
• Organizations with expired AAAHC accreditation that are again seeking accreditation through AAAHC.

Organizations must complete an Application for Survey for their initial survey. After review of the completed Application for Survey and supporting documentation, the AAAHC will contact the organization to establish survey dates.

Re-accreditation surveys are conducted for organizations that are currently AAAHC-accredited and seek continuation of accreditation following a three-year term.

Interim surveys are conducted for organizations that are currently AAAHC-accredited and for which oversight is required to assess ongoing compliance with the accreditation Standards.

The Accreditation Association has been granted “deemed status” by the Centers for Medicare & Medicaid Services (CMS) for Ambulatory Surgery Centers (ASC) and also for HMOs and PPOs that participate in the Medicare Advantage program. As a result, ASCs and HMOs/PPOs have the option to choose an accreditation survey using the AAAHC Standards in the Handbook, or to choose the AAAHC/Medicare deemed status survey that includes a review of applicable Medicare requirements.

Information on Medicare Deemed Status Surveys for ASCs

Random Surveys

To support the AAAHC’s ongoing quality assurance initiatives, an accredited organization may be selected for a random survey from 9 to 30 months after an accreditation survey. Random surveys are unannounced. Organizations are selected on a proportionate basis across practice settings, geographic areas and accreditation decision categories. These unannounced surveys, which are conducted by one surveyor and may last one full day, are a means by which the AAAHC can evaluate the consistency and quality of its program, while also demonstrating to the public and regulators that accredited organizations remain committed to the AAAHC Standards throughout the accreditation cycle. Random surveys also provide the AAAHC and its surveyors with opportunities to further consult with accredited organizations in the interval between regular surveys. No fee shall be charged to the organization when a random survey is conducted.

Discretionary Surveys

Discretionary surveys are conducted “for cause,” when concerns have been raised about an accredited organization’s continued compliance with AAAHC Standards. An accredited organization may undergo a discretionaery survey at any time, without advance notice, and at the discretion of the AAAHC. A fee may be charged to the organization when a discretionary survey is conducted.