Posted in: Triangle Times Today

Volume 3 | Issue 5 | May 2024

Change Notification Updated with 1095 Engage

45 years ago, AAAHC was founded to “encourage and assist ambulatory health care organizations to provide the highest achievable level of care for recipients in the most efficient and economically sound manner. AAAHC accomplishes this by the operation of a peer-based assessment, consultation, education and accreditation program.” These values hold true today, as embodied in our mission statement, Improving health care quality through accreditation.

The AAAHC 1095 Strong, quality every day philosophy is central to our strategy, defines our values, and emphasizes the importance of quality practices and organization readiness throughout all 1,095 days of the accreditation term  and every day during which a patient is receiving care.

In April, AAAHC introduced the 1095 Engage accreditation management system. As the system name reflects, our 1095 Strong, quality every day philosophy has been core to system design. This exciting, new accreditation/certification and compliance-management portal provides a single-source operations solution for documentation, client profile information management, communication, and streamlined workflow.

To facilitate system transition for currently enrolled organizations, AAAHC leveraged data from the prior application and surveys to provide the foundation for the 1095 Engage living profile. To take full advantage of the engagement benefits this new system offers, including curated Standards and a streamlined renewal process, AAAHC needs to know more about your organization and the services you provide. In collaboration with accredited organizations, we accomplish this goal through expansion of the Application and use of the Change Notification process.

Exploring the Change Notification process within 1095 Engage

A Change Notification is a structured electronic process that facilitates communication and management of any updates or modifications made to the organization’s living profile or application. Organizations participate in the  accreditation/certification in good faith. This means that we expect organizations to maintain an accurate profile and routinely engage with AAAHC regarding changes that may impact the care delivered to patients and the safety of employees. This change management process is central to ensuring your accreditation/certification profile remains current and drives the consistency, quality, and accuracy of each organization’s Profile and applicable Standards curation. Throughout the 1095 cycle, the designated Primary Contact can submit significant changes that have occurred within the organization.

1095 Engage will guide you through the necessary information and documentation requirements and provides an  easy-to-use portal to conveniently submit information. This includes:

  • For organizations actively maintaining accreditation or certification, as part of the transition to 1095 Engage, leverage the Change Notification process to update the Application/Profile to include all required information necessary for compliance and accurate Standards curation.
  • Thereafter, AAAHC requires the organization to notify AAAHC within 15 days of any significant changes including organizational, ownership, operational, or quality of care events. Refer to Standard ADM.100 in the AAAHC Handbook, v43.
  • Each organization must determine what it reasonably deems significant based on its organizational policies and applicable CMS, state, and local requirements.
  • States have different reporting requirements, and AAAHC expects organizations to understand these requirements and demonstrate compliance at time of survey and on an ongoing basis.
  •  In addition, organizations must notify AAAHC of any change notifications submitted to CMS or state regulatory bodies and provide the subsequent approval from these entities. If the organization does not have regulatory notification requirements, then operating in good faith, any changes that may impact patient care or are within the reasonable definition of significant should be reported to AAAHC.
  • On an annual basis, when significant changes occur, and when applying for renewal for accreditation or certification, the organization’s Primary Contact will review the 1095 Engage living profile for accuracy, provide any recent updates, and upload current supporting documentation, as necessary.
  • Through the 1095 Engage Annual Attestation requirement, the organization is attesting to the accuracy of its profile, completion of a gap assessment against current Standards, and ongoing compliance to AAAHC Standards.

To notify AAAHC of changes and update the Application/Profile, complete and submit the required documents within the Change Notification section of the 1095 Engage portal. Depending on the change, AAAHC will determine the action required including whether an intracycle onsite survey is necessary to assess the changes. Note that most changes do not require an intracycle onsite survey.

The 1095 Engage Application/Profile contains six sections. For effective use, upon initial system access and setup, all organizations will need to follow the steps outlined below to complete and update the Application or Profile.

  1. Update unlocked application sections. Review and update all  unlocked fields in each section. For locked fields, a Change Notification is required using the steps described below. Please note the order in which these steps are completed to ensure an accurate, comprehensive update. For each submitted Change Notification, edited sections will update following AAAHC review and approval.
  2. Complete Ownership and Scope of Service Notifications.
  3. Complete the Reporting Change Notification.
  4. Complete the Required Field Update Change Notification. AAAHC will review and approve each submitted Change Notification and determine whether additional action is required. Organizations will be contacted through 1095 Engage with any questions or required clarifications.
  5. For organizations within 180 days of their triennial Anniversary Date (within the “Application Open” window), complete and submit the Initial/Renewal Application. Once AAAHC approves each Change Notification, additional fields may open up relevant to the change. Complete the update for each section. To finalize the section and indicate it as completed, select the SAVE button at the bottom of each section. If any sections are incomplete, repeat the Change Notification submission steps outlined above. Once the Application Attestation is completed, the Primary Contact or Chief Medical Officer (CMO) can attest to the accuracy of the information and submit the application.
  6. As changes occur throughout the 1095 cycle, utilize the Change Notification process.
  7. Complete the Annual Attestation. 45 days prior to your annual Anniversary date, AAAHC will send the Primary Contact and CMO a reminder email and trigger a task to appear on your 1095 Engage dashboard to complete your Annual Attestation. This process includes conducting a gap assessment and possible corrective action against current Standards, reviewing the profile, utilizing the Change Notification process to submit any changes as necessary, and attesting to the accuracy of your profile. Once all sections are reviewed and updated as necessary, the Attestation menu option on the top screen menu bar will prompt the Chief Medical Officer to electronically attest to the accuracy of the organization’s Application. This process ensures that  Standards curation is up to date and the organization maintains compliance.

Remember, accreditation/certification is not automatically maintained when an organization undergoes significant changes.

Change Notification FAQs

The Q&A below provides additional clarifications on 1095 Engage and Change Notification.

When do we submit a change notification?

With 1095 Engage launch, all organizations within an active term will be required to update their profiles for ongoing compliance, in preparation for renewal, and to view their most current and accurate curated Standards. AAAHC expects organizations to participate in the Change Notification process in good faith. Each organization must determine what it reasonably deems significant based on its organizational policies and applicable CMS, state, and local requirements.

Reportable changes must be submitted to AAAHC through the Change Notification process within 15 calendar days of the change. In addition, organizations must notify AAAHC of any change notifications submitted to CMS/State regulatory body and provide the subsequent approval.

States have different reporting requirements, and AAAHC expects organizations to understand these requirements and demonstrate compliance at time of survey and on an ongoing basis. If the organization does not have regulatory notification requirements, then operating in good faith, any changes that may impact patient care should be reported to AAAHC as well.

As required in the Application/Profile, how do we update our 1095 Engage Contact List and add users?

When logged into 1095 Engage, access the Contacts section of your Application/Profile. This section includes individuals associated to your organization with specific roles relevant to your operation  and accreditation/certification. Updating and editing these contact individuals does not require a Change Notification and can be updated by the Primary Contact at any time.

In addition to a list of organization contacts, your Profile also contains 1095 Engage Users. These are individuals that have 1095 Engage user profiles and are permissioned with read/write capabilities in the system. For each  organization, AAAHC requires at least one and preferably two Primary Contacts (also referred to as Client Admin)  and a designated CMO User. These two roles are critical to system operation and must be maintained by the organization throughout the 1095 cycle.

To create or add Primary Contact or CMO users in the Application/Profile Contacts section, go to the bottom of the Contacts list and click the link that directs you to create new users. By clicking that link, you can activate the “Create a new user” page and link a new user to your organization. Once activated, this individual will receive an email confirmation and instructions to login. Note that users cannot share email addresses; email addresses must be unique.

What types of organizational changes must be reported to AAAHC?

Any organizational changes that may impact patient care or are within the reasonable definition of significant should be reported to AAAHC. Reportable changes include operational, quality of care, and structural changes. Examples include, but are not limited to:

  • Relocations
  • Renovations
  • Adding/removing Child Business Unit (CBU)/locations
  • Increasing/decreasing anesthesia levels
  • Organization name changes
  • Ownership change

For a complete list, please review the current Handbook Policies & Procedures.

If our organizational change is not ready or fully implemented, do we need to report partial progress?

Organizations can initiate a Change Notification and save it in their profile pending final documentation, submission, and approval. Once your final documentation is available, complete the Change Notification and submit the change(s) and supporting documentation as required to AAAHC. AAAHC will not approve incomplete changes; all required documentation must be submitted prior to AAAHC’s review and determined to be acceptable through the review process.

Do I need to submit changes separately for my Child Business Unit (CBU)?

Change Notifications are specific to each location. Select the Child Business Unit (CBU) location for which you would like to submit a change from the dropdown list of organizations within your hierarchy. Once selected, you will have access to the Change Notification section which facilitates submitting changes specific to the location/site.

Do I need to notify AAAHC when my management company/Managing Business Unit (MBU) changes? If so, how do I update my Profile?

Organizations are encouraged to frequently verify the accuracy of their hierarchy and affiliations. In 1095 Engage you can review the Hierarchy section that includes organizations that are connected or affiliated with your  organization. This can include your Managing Business Unit(MBU) or associated Child Business Units (CBU). You can update/edit this information from this screen. While associated, an MBU can view an associated organization’s profile, application, survey reports, and accreditation/certification decisions. For this reason, any changes to your
hierarchy should be processed promptly.

A Hierarchy Change Notification must be submitted when an organization requests to be disconnected from a Parent Business Unit (PBU) and/or MBU. If an organization is not currently connected to a PBU and/or MBU they can submit an affiliation request through the Hierarchy window.

How can I learn more about the 1095 Engage Change Notification process?

To learn more about the Change Notification process, click here to access the full 1095 Engage curriculum through 1095 Learn. Select the course titled, Profile Update: Start Here for Renewal Success, for an overview of the Change Notification procedure for updating your Application/Profile.

If you don’t have a 1095 Learn Learning Management System account already established, you will be prompted to create it. This curriculum provides a comprehensive review of 1095 Engage including a separate webinar module focused on the Change Notification process.

Conferences & Exhibits

  • Florida Society of Ambulatory Surgical Centers (FSASC)
    July 17–19, Orlando, FL
  • Texas Ambulatory Surgery Center Society (TASCS)
    July 24–26, Galveston, TX
  • California Ambulatory Surgery
    Association (CASA)
    September 4–6, Anaheim, CA, Booth 37
  • Becker’s Healthcare
    October 30–November 2, Chicago, IL

1095 Learn

2024 Achieving Accreditation

  • September 16–18 Virtual
  • December 12–13 Onsite, Las Vegas, NV

To learn more, visit/AAnews


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