Accreditation & Certification

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dreamstime l 37103426 - Accreditation & CertificationOur “standard” package for accreditation and certification is a subset of the services listed in the Turnkey option. Services may be added to the Standard package at any time during the development process. Our standard package duties include the following:

(a)Review of Physical Facility/Creation of Space Plan

For existing facilities, Advantage will review the physical facility to ensure that it meets the current guidelines of the chosen accreditation agency. Advantage will make recommendations regarding the physical facility in accordance with the chosen accreditation agency’s standards and to ensure good operational flow. NOTE: Standards change along with interpretation of the standards so what was appropriate in the last accreditation cycle may need revision for the current cycle.
For new facilities, Advantage will work with the chosen architect (Advantage can recommend experienced architects, if needed) to design a space plan which meets the chosen accreditation agency’s standards and Medicare guidelines, if Medicare deemed-status certification is desired. Two visits during construction are included with new facilities.

(b) Equipment Planning

For existing centers, Advantage will review the equipment present in the Center, if any, and make recommendations for any additional equipment. Advantage shall work closely with Client to prepare an equipment list and a corresponding budget.

dreamstime l 35728266 - Accreditation & CertificationFor new Centers, Advantage shall prepare an equipment list and corresponding budget for the Center to ensure that the Center obtains all the equipment required by the chosen approval. Advantage shall not be responsible for nor is given permission to order equipment for Client. Advantage shall provide the equipment list and equipment layout to the engineers and architect to ensure that they design systems that will support the required equipment and meet Medicare regulations. Advantage shall provide direction regarding the finishing details of the surgery center including appropriate finishes and fixtures as well as special items such as door hardware and plumbing fixtures.

(c) Liaison With Accreditation Agency

dreamstime l 40190077 - Accreditation & CertificationAdvantage will act as liaison with the chosen accreditation agency, Medicare fiscal intermediary, California Department of Public Health and CMS throughout the accreditation/certification process. This includes continued contact from application submittal to survey and post-survey follow-up including the Plan of Correction through to the assignment of the Medicare provider and submitter ID numbers.

(d) Operating Manuals

Advantage shall prepare and provide outpatient surgery (for Medicare certification) or office-based operating manuals, protocols, and procedures that comply with applicable requirements and shall familiarize the Client’s staff members with such manuals. These include the Policies and Procedures manual, Quality Assurance/Performance Improvement Program, Risk Management Program, HIPAA and OSHA programs. The manuals will include personnel policies and an Employee Manual. Should manuals other than provided by Advantage be used, Advantage cannot assume responsibility for their compliance with accreditation standards.

(e) Orientation of Nursing and Administrative Staff

dreamstime l 40274910 - Accreditation & CertificationAdvantage shall assist in the orientation and training of the Client’s nursing director and/or Administrator in regard to accreditation and certification standards and shall familiarize the nurse and staff with respect to the operation of the office/center including preparation of necessary logs, checklists, credentials and other documentation. Advantage will direct the staff in the required documentation and check completeness of documentation at subsequent visits. A total of five (5) on-site visits are included in the Agreement. The first visit will be with the Project Manager or Project Director (RN) and Associate where orientation to many of the documents will begin and a To Do list provided. The next three on-site visits will be with a Project Associate to work with the Nursing Director and staff at with each visit lasting between four and six hours where progress with paperwork, equipment and physical changes will be monitored. To Do lists will follow each visit. The final visit will be with the Project Manager or Project Director and Associate to do a final checkup of the office/center’s survey readiness. Staff must be available without interruptions during these meetings. If staff changes after orientation meetings have taken place, the total number of visits included in the agreement remains. If additional visits are required, they shall be billed at the Additional Services (g) rate.

(f) Paperwork for Accreditation

dreamstime l 39360108 - Accreditation & CertificationAdvantage will complete the accreditation and Medicare certification application material with the assistance of Client and staff. Advantage will provide templates for medical records, credentialing files (including job descriptions and competencies for nursing and tech, applications, privilege lists and other forms for physicians), logs and checklists as well as QI studies, benchmarking and meeting minutes. Advantage provides forms for infection control monitoring which are required to document an effective infection control and prevention program as well as an effective Quality Assurance/Performance Improvement program. Advantage will provide orientation to the requirements of accreditation and how the forms meet those requirements. If Advantage forms are NOT used, Advantage cannot be responsible for the result of the surveyor’s review.

(g) Additional Services

Advantage may provide additional services to Client that are not listed in this Agreement at varying rates for the Project Manager, Project Director (RN) and Project Associate. Advantage will inform Client prior to the services being performed if they are not within the scope of the agreement and provide an estimate for the time necessary to complete the additional services.

Our “standard” package for accreditation and certification is a subset of the services listed in the Turnkey option. Below is a comparison of the two services.