Service Specific Standards:

  • address requirements additional to CORE which are unique to the specific service or business line.
  • incorporate, where required, CMS requirements for home health, hospice and DMEPOS.

All CHAP Standards of Excellence are built upon four underlying principles, which serve as the sections of the standard manuals. These principles are: 1) Structure and Function; 2) Quality of Services and Products; 3) Availability of Human, Financial and Physical Resources; and 4) Long Term Viability. The following describes more about the content in each section.

    1. The Organization’s Structure And Function Consistently Supports Its Consumer Oriented Mission
      1. Statement of Mission
      2. Organizational Structure And Functional Mechanisms
      3. Organizational Relationships/Chart
      4. Administrative Authority and Responsibility
      5. Organizational Policies
      6. Communication and Information to Consumers
      7. Ethical Issues
      8. Research Initiatives
    2. The Organization Consistently Provides High Quality Services And Products.
      1. Business and Clinical Practices
      2. Client Access to Care, Services and Products
      3. Emergency Planning
      4. Coordination of Operations
      5. Client Records
      6. Performance Improvement
      7. Safety of Employees and Clients
      8. Complaints
    3. The Organization Has Adequate Human, Financial, And Physical Resources To Accomplish Its Stated Mission And Purpose.
      1. Human Resources
      2. Contracts
      3. Financial Management
      4. Financial Information System
      5. Physical Facilities
      6. Management Information System
    4. The Organization Is Positioned For Long Term Viability.
      1. Strategic Planning
      2. Annual Evaluation of the Organization

    Each standard statement may be comprised of four (4) parts to further specify requirements:

      1. Standard statement - A blueprint for success that recognizes excellence
      2. Criterion - A statement that defines in detail the requirements of the standard
      3. Element - A component of each criterion that delineates requirements
      4. Sub-element – Additional statements that provide more definition of selected elements.

      Evidence Guidelines

      Standards are formatted with relevant Evidence Guidelines. The evidence guidelines are not standards or criteria. They are intended to provide examples to the organization and to the CHAP Site Visitor. The examples may be used to determine organizational compliance with the standards. The Site Visitor will clarify, verify and quantify data to substantiate findings. The letter preceding each evidence guideline indicates the source of the information to be used by the Site Visitor in the accreditation process. Sources of evidence are:

      D - Documentation 
      I - Interview 
      O - Observation 
      S - Surveys