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Document Document

ACCREDITATION PROCESS AND POLICIES
POLICIES REVISED July 2021

Contents
AASM ACCREDITATION APPLICATION GUIDE .............................................................................................. 4 ACCREDITATION PROGRAMS....................................................................................................................... 4 Sleep Facility................................................................................................................................................... 4 Independent Sleep Practice .............................................................................................................................. 4 Durable Medical Equipment Supplier............................................................................................................... 5 APPLICATION TYPES ...................................................................................................................................... 5 New Accreditation ........................................................................................................................................... 5 Reaccreditation ................................................................................................................................................ 5 Special Circumstance Application.................................................................................................................... 5
ACCREDITATION STATUS ................................................................................................................................. 5 Accreditation ....................................................................................................................................................... 5 Denied Accreditation ........................................................................................................................................... 6 Revoked Accreditation......................................................................................................................................... 6 Suspended Accreditation...................................................................................................................................... 7 Accreditation Flags.............................................................................................................................................. 7 Operational Flag .............................................................................................................................................. 8 Administrative Flag ......................................................................................................................................... 8
APPLICATION SUBMISSION PROCESS ............................................................................................................. 8 Reaccreditation Application Submission............................................................................................................... 9 Early Reaccreditation........................................................................................................................................... 9
ACCREDITATION APPLICATION PAYMENT ................................................................................................. 10 Fees................................................................................................................................................................... 10
APPLICATION REVIEW PROCESS ................................................................................................................... 11 ACCREDITATION APPROVAL PROCESS ........................................................................................................ 12 SITE VISIT PROCESS ......................................................................................................................................... 12
Scheduling......................................................................................................................................................... 13 On-site Site Visit Process................................................................................................................................... 13 Remote Site Visit Process .................................................................................................................................. 13 Cancellation Policy/ Process .............................................................................................................................. 14 FINAL VERIFICATION PROCESS ..................................................................................................................... 14 Submission of Information in Response to Provisos ........................................................................................... 15 WITHDRAWALS................................................................................................................................................. 15 SPECIAL CONSIDERATIONS ............................................................................................................................ 15 Change of Facility Director................................................................................................................................ 16

Submit the following for the new facility director: ............................................................................................. 16 Expansion of the Sleep Facility.......................................................................................................................... 16 Change of Control/Ownership of the Facility/Program ....................................................................................... 16 Change of Primary Contact................................................................................................................................ 17 Relocation ......................................................................................................................................................... 17 Relocation in Conjunction with an Ownership Change ....................................................................................... 18 RECONSIDERATION PROCESS ........................................................................................................................ 18 LOGO USAGE AND ADVERTISEMENT OF ACCREDITED STATUS ............................................................. 19

AASM ACCREDITATION APPLICATION GUIDE
The first sleep center was established in 1964 at Stanford University for the diagnosis and treatment of narcolepsy. In 1975, the Association of Sleep Disorders Centers, a predecessor of the American Academy of Sleep Medicine (AASM), was formed and a Certification Committee was appointed to establish and maintain standards for the evaluation and treatment of patients with sleep disorders. The Montefiore Hospital Sleep Center, New York, was the first to be accredited on April 27, 1977.
The Accreditation Committee (formerly the Certification Committee) maintains the Standards for Accreditation ("Standards"). Final approval of the Standards rests with the AASM Board of Directors. The Standards are updated periodically to remain consistent with changes in technology and clinical practice.
Accreditation Network
In the field of sleep medicine, it is becoming common place for accreditation programs to be associated with one another either under a hospital, large health system or multi-clinic sleep practice. To improve the accreditation experience for accreditation programs that share commonalities, the AASM accreditation process will begin identifying and sharing information between these accreditation programs within the same accreditation network.
An Accreditation Network includes other sleep programs that may be under the same ownership/legal entity and operate under the same policies and procedures. Accreditation programs that are a part of the same accreditation network will:
· Share specific information between applications · Share the same accreditation expiration dates · Share the same site visit schedules · Be eligible to participate in volume pricing
ACCREDITATION PROGRAMS
AASM accreditation is a voluntary activity, providing recognition that an entity meets rigorous standards set forth by the AASM. The AASM accredits sleep disorders facilities, independent sleep practices and durable medical equipment suppliers.
Sleep Facility
A Sleep Facility is comprised of both a clinic, where patient evaluation and management occur, and a laboratory, where diagnostic testing is administered through in-center sleep studies and home sleep apnea tests (HSATs).
Independent Sleep Practice
An Independent Sleep Practice (ISP) is a sleep practice that manages patients with all sleep disorders and conducts diagnostic testing through the use of HSATs only; an independent sleep
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practice does not have a lab for in-center sleep testing.
Durable Medical Equipment Supplier
A Durable Medical Equipment (DME) Supplier supplies sleep-related DME equipment to nonMedicare patients. This includes both freestanding suppliers, as well as sleep facilities or practices that provide DME equipment to their patients.
APPLICATION TYPES
The types of applications available for Sleep Facility, Independent Sleep Practice or DME Supplier accreditation are:
New Accreditation
New accreditation is available to any entity (Sleep Facility, ISP, and/or DME Supplier). Entities applying for new accreditation, who have been in operation less than 6 months, will receive an accreditation flag until the completion of the Final Verification Process. New accreditation is granted for five years unless the adjusted term of the expiration date shared by the accreditation network is less.
Reaccreditation
An accredited program (Sleep Facility, ISP and/or DME Supplier) must complete a reaccreditation application prior to the end of the accreditation term in order to achieve continued reaccreditation without delay or lapse in status. An accreditation flag will be applied to an entity if approval for reaccreditation has not been achieved by their accreditation expiration date; an entity may not exceed three (3) months past their accreditation expiration date.
Reaccreditation applications are due 6 months prior to the program's accreditation expiration date. Applications for reaccreditation will not be accepted more than 10 months in advance of the expiration date. See Reaccreditation Application Submission for further details.
Special Circumstance Application
Special Circumstance Applications are used when an accredited program relocates to a new location. Review of the new location is performed to ensure the new location is compliant to the Standards for Accreditation. The sleep program must notify the AASM to open the application manually. Approval of a Special Circumstance Application grants the accredited program continuation of their current accreditation term.
ACCREDITATION STATUS
Accreditation
Accreditation is granted by the AASM Accreditation Committee to entities that demonstrate compliance with all the Standards for Accreditation, Independent Sleep Practice Standards for Accreditation or DME Supplier Accreditation Standards. Once approved (and any provisos resolved), entities will receive an accreditation certificate in the mail.
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New Accreditation (Single)
A new single accreditation (not part of an accreditation network) is granted accreditation by the AASM Accreditation Committee for a period of 5 years from the date of Accreditation Committee approval.
New Accreditation (Accreditation Network)
A new accreditation under an established accreditation network will sync (based upon an adjusted term) with the shared accreditation terms expiration date. Approval of the adjusted accreditation term will be granted from the date of approval by the AASM Accreditation Committee. The adjusted terms are as follows:
· If a new accreditation program applies for accreditation when the shared accreditation expiration date term is two (2) or less years away, then the new accreditation will initially receive a lengthened term by adding the two (2) years or less to their five year accreditation term (equaling a seven (7) or less year accreditation term). A reaccreditation application will be required at the time the accreditation network applies for their reaccreditation applications.
· If a new accreditation program applies for accreditation when the shared accreditation expiration date term is more than two (2) years, then the new accreditation will initially receive a shortened term (anywhere between two (2) to five (5) years) to align with the shared accreditation expiration date. A reaccreditation application will be required at the time the accreditation network applies for their reaccreditation applications.
Reaccreditation (Single or Accreditation Network)
Reaccreditation is granted by the AASM Accreditation Committee for a period of 5 years from the initial accreditation expiration date term. See Reaccreditation Application Submission for further details.
Denied Accreditation
Entities that: · receive one or more provisos on mandatory standards, or · receive more than 10 provisos on non-mandatory standards.
will be denied accreditation; no refunds will be given. If currently accredited, the accreditation term ends the date of denial. An appeals process is available to entities that did not fulfill the accreditation requirements resulting in denial of accreditation. An entity may also reapply, submit all applicable fees and begin the accreditation process again.
Revoked Accreditation
If an entity is not in compliance with the Standards for Accreditation, Independent Sleep Practice Standards for Accreditation, or DME Supplier Accreditation Standards, their accreditation may be revoked. Examples of reasons for revocation include, but are not limited to:
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a. Illegal activity. b. Incomplete or inadequate application. c. AASM Board of Directors or Accreditation Committee action. d. Violation of mandatory standards. e. Non-completion or failure of a site visit. f. Initiation of any government investigation or adverse action taken against the facility
that impacts the ability to meet any standards. g. Non-compliance to provisos.
Failure to notify the AASM within 30 days of a, d or f may result in revocation of accreditation. The accreditation term ends the date of revocation; no refunds are given.
If accreditation is revoked for any reason other than non-completion of a site visit, the entity is required to wait one full year before applying for accreditation. If accreditation was revoked due to non-completion of a site visit, the entity may reapply, submit all applicable fees and begin the accreditation process again at any time.
Suspended Accreditation
If an accredited entity loses its ability to meet the Standards for Accreditation, Independent Sleep Practice Standards for Accreditation, or DME Supplier Accreditation Standards, (e.g., loss of facility director or principal medical staff member), the Accreditation Committee may approve that the facility's accreditation status be suspended until the entity can once again meet the Standards for Accreditation, Independent Sleep Practice Standards for Accreditation, or DME Supplier Accreditation Standards.
While accreditation is suspended, the entity is not accredited. The entity may not use the AASM member facility logo, or other materials that imply accreditation by the AASM. All references to AASM accreditation in advertisements must cease.
For accreditation to be reinstated, the facility director must provide written documentation of changes that have been made to correct deficiencies. A site visit may be necessary, at the entity's expense, to determine whether the entity now meets the Standards for Accreditation, Independent Sleep Practice Standards for Accreditation or DME Supplier Accreditation Standards. It is not necessary to submit a new application for accreditation.
When accreditation is reinstated, full accreditation resumes for the remainder of the original accreditation term. A reinstatement fee of $250 will be charged when the entity is ready to resume its operations in full compliance with the Standards of Accreditation, Independent Sleep Practice Standards for Accreditation, or DME Supplier Accreditation Standards.
Suspended accreditation status cannot be continued beyond one year. Failure to meet all standards within one year will result in revoked accreditation. Failure to notify the AASM of changes in an accredited entity that may lead to suspended accreditation is cause for denial of future accreditation.
Accreditation Flags
The AASM utilizes flags to identify entities that maintain accreditation with conditions. Flags 7

are classified as either operational or administrative. The following flags are applied, downgraded (operational to administrative), or removed after each of the following conditions have been met:
Operational Flag · Patient Management Flag: An entity has been in operation for less than 6 months when applying for New Accreditation and has an outstanding site visit. Failure to complete a site visit in the allotted period (12 months from the date of approval) may result in revoked accreditation. This flag will be downgraded to an administrative flag once a completed Patient Volume and Statistics form has been submitted by the entity and reviewed and approved by the AASM. See Site Visit Process for further details. · Provisory Flag: An entity has outstanding provisos. Failure to complete requirements of provisos in the allotted proviso period (3 months) may result in revoked accreditation. See Submission of Information in Response to Provisos for further details.
Administrative Flag · Site Visit Flag: An entity has an outstanding site visit. Failure to complete a site visit in the allotted period (12 months from the date of approval) may result in revoked accreditation. · Interim Accreditation Flag: An entity is pending approval of reaccreditation beyond their current expiration date. A reaccreditation application was submitted before their expiration date but approval from the Accreditation Committee for Reaccreditation was not obtained prior to their Accreditation expiration date. Failure to achieve reaccreditation in the allotted time (3 months past expiration) will result in expiration of accreditation and void of the current application. If the facility wishes to pursue accreditation at that time, a new Accreditation application with fee must be submitted. See Reaccreditation Application Submission for further details.
The public can view assigned flags on the accreditation account via the AASM Accreditation Directory.
APPLICATION SUBMISSION PROCESS
It is recommended that you review the accreditation section of www.aasm.org for Frequently Asked Questions (FAQs), accreditation resources, information about the accreditation process, and the most current Standards for Accreditation, Independent Sleep Practice Standards for Accreditation or DME Supplier Accreditation Standards.
Please follow these steps in the application process: 1. Read the Accreditation Process and Policies document completely before beginning the online application or gathering supporting materials.
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2. Decide the type(s) of Accreditation Program and Application you will apply for. 3. Complete and Submit the online application along with payment to begin review.
The length of time an individual application spends in the accreditation process varies widely depending upon the quality of the application, the volume of applications currently in process, and the speed with which responses are received from the applicant.
The Accreditation Committee oversees the accreditation process. Site visitors are boardcertified sleep specialists who are or have been directors of AASM-accredited sleep facilities.
The AASM reviews all applications using the most current Application and Standards for Accreditation regardless of the age of the application submitted. The current Application for Accreditation is freely available at www.aasm.org.
Separate applications must be submitted for each facility seeking accreditation. Each facility location must be capable of operating independently. The AASM does not accredit satellite facilities/locations.
Reaccreditation Application Submission
A reaccreditation application must be completed and submitted prior to the end of the accreditation term in order to achieve continued reaccreditation without delay or lapse in status. Reaccreditation applications must be received no later than six (6) months prior to the expiration date of the current accreditation term. Entities failing to do so may still submit an application up to the actual expiration date; however, a late fee of $750 will be assessed.
Entities who submit a reaccreditation application prior to the end of the accreditation term but continue in application past the expiration date will receive an accreditation flag for a period of three (3) months past the accreditation term. Entities who fail to achieve accreditation within three (3) months past the accreditation term will expire, and the current application will be void. Entities will be required to submit a new accreditation application and will experience a lapse in accreditation status until new accreditation is approved. The AASM reserves the right to make exceptions to this policy when it deems warranted.
Accreditation of entities failing to submit the reaccreditation application by the expiration date will expire and the entity will be required to submit a new accreditation application. The original accreditation date will be lost, and a site visit will be required. Entities will experience a lapse in accreditation status until new accreditation is approved.
Early Reaccreditation
Accredited entities that relocate less than 18 months before their accreditation expiration date may complete an early reaccreditation application. The early reaccreditation option is subject to AASM approval. Contact the AASM for more information regarding this process.
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ACCREDITATION APPLICATION PAYMENT

The facility's designated staff member and facility director complete the online application; the facility director attests to the accuracy of the information and submits the application with the accreditation fee to the AASM.

Fees
Accreditation Category
Sleep Facility Independent Sleep Practice DME Expedited Accreditation

New (Single) Application Fee /Member
Reaccreditation Fee

$4500 $4500 $2000

$500

Non-Member Reaccreditation Fee
$7200 $7200 $2000

New Application (Accreditation Network) Fee: A new accreditation under an established accreditation network will receive an accreditation fee based upon their adjusted accreditation term. The fee applied to their adjusted accreditation term is a calculation of the total adjusted term length (number of year(s), month(s), day(s)) to the corresponding accreditation fee above.

Reaccreditation late fee or application query late fees are assessed $750.

Use of a business associate agreement (BAA) other than AASM's BAA, or any request for modification to AASM's BAA, is assessed a $500 custom BAA fee.

Please note that fees are subject to change without notice. Fees apply to the continental United States. Additional fees may apply for facilities located outside the continental United States.

Volume pricing is available for networks that maintain more than one (1) accreditation program (Sleep Facility, ISP, DME) with the AASM. Determination is based upon the number of active accredited programs as a part of the Accreditation Network at the time of submission for an accreditation application.

Number of Accreditation Programs with AASM
2-4 5-9 10-14 15-19 20+

Discount Percentage (Applied to Each
Accredited Program) 5% 10% 15% 20% 25%

Once the entity's payment is received, the AASM accreditation coordinator will email a receipt of payment to the designated primary contact.
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APPLICATION REVIEW PROCESS
The online application is reviewed by an Accreditation Reviewer to evaluate all submitted documentation, materials and forms to determine compliance to the standards.
Review of the online application typically takes 4-6 weeks from the date payment is received. If payment is not received within 14 calendar days after the submission of the accreditation application, the application will be voided, and the entity must reapply. The application will not be reviewed until payment is received.
Once the application review is completed by the AASM, the entity may be asked to submit additional information to demonstrate compliance with the Accreditation Standards. The entity's primary contact will receive an email indicating there are outstanding issues associated with the application. The entity will then need to log into the online application to resolve the issues within 14 days.
· Applicants who do not respond to the issues within 14 calendar days will be assessed a $750 late fee.
· If a response to these issues is not received within 28 days, the application is voided. o $1,000 will be refunded to facilities applying for new accreditation and reaccreditation. To reapply, the entity must submit a new application along with the full accreditation fee payment.
1. If the application does not pass the review process, the entity will be notified that the application has been rejected. $1000 will be refunded.
2. The AASM reserves the right to return incomplete applications. 3. The facility director may request reconsideration of the review decision in writing to the
AASM Board of Directors within thirty (30) days of notification by the AASM (See RECONSIDERATION PROCESS).
Types of Issues: a. Mandatory: Issues related to mandatory Accreditation Standards. a. Issues related to mandatory standards must be resolved prior to the scheduling of the site visit. b. All mandatory standards must be resolved prior to being presented for approval by the AASM Accreditation Committee. Failure to meet one or more mandatory standards will always result in denial of accreditation. No exceptions will be made.
b. Non-Mandatory: Issues related to non-mandatory Accreditation Standards will be included in the online application but are not required to be resolved until the date of the site visit. The site visitor will determine compliance with non-mandatory standards onsite during the site visit. a. The entity may have no more than 10 outstanding non-mandatory issues prior to being presented for approval by the Accreditation Committee. b. All outstanding issues related to non-mandatory standards must be addressed at the site visit. 11

c. A non-mandatory proviso must be resolved within three (3) months of the notification date stated by the AASM.
d. If a site visit is not required for an application, all issues must be resolved in the application, regardless of issue type.
ACCREDITATION APPROVAL PROCESS
Upon completion of the application review process, a recommendation regarding the accreditation status of each program (sleep facility/independent sleep practice/DME Supplier) is submitted to the Accreditation Committee for final approval.
The Accreditation Committee will render one of two decisions:
a. Accreditation approved: The entity is granted full accreditation from the date of approval by the Accreditation Committee. Continued accreditation may be dependent upon successful completion of a site visit.
b. Accreditation denied.
SITE VISIT PROCESS
Once a new or reaccreditation application has been completed, all required documentation has been submitted and reviewed, and the program has received the corresponding approval by the Accreditation Committee, an onsite site visit will be scheduled within the first year (12 months) from the accreditation approval date.
Entities applying for new accreditation, who have been in operation for less than 6 months, must complete and submit Patient Volume and Study Statistics prior to scheduling a site visit. The site visit must be completed within six (6) to twelve (12) months from the date of approval by the Accreditation Committee. Once Patient Volume and Study Statistics has been submitted, reviewed and approved in application, the entity will be moved from a Patient Management Flag to a Site Visit Flag.
Special Circumstance Applications will receive a remote site visit to ensure the sleep facility's physical space meets applicable AASM Standards for Accreditation. Following the remote visit, the Accreditation Committee will determine continued accreditation status. Accreditation, if approved, will be granted for the remainder of the original accreditation term. An on-site site visit will be required at the next accreditation cycle.
Please note a site visit is also not required for DME Supplier Accreditation, but the AASM reserves the right to perform a site visit on a DME supplier for any reason.
A Business Associate Agreement must be signed by both parties (the AASM and the facility/practice) prior to the site visit. If the agreement is not fully executed, the site visit will be postponed and/or cancelled.
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Entities should NEVER contact their site visitor directly; all communication is to be directed through the AASM Accreditation Coordinator assigned to the facility.
AASM Staff and Site visitors are not allowed to receive any gifts, promotional items or any other monetary remuneration from the facility.
Scheduling
Based on the site visitor's availability, a visit date will be selected by the AASM. The facility will then be notified via email that a site visit has been scheduled. The facility will be offered one (1) date. If this date conflicts with the facility's schedule, a second and final date will be offered. If the second date is not accepted, the AASM reserves the right to cancel the site visit.
a. If the Entity does not receive a site visit within the first year (12 months) from the accreditation approval date, the Entity's accreditation may be revoked.
On-site Site Visit Process
The facility director, one (1) additional professional staff member (the most active in the sleep program) and one (1) night technologist must be present during the site visit.
The entity's designated individual must complete the site visit itinerary with the names of all required staff to be interviewed. The itinerary must be submitted to the AASM Accreditation Department at least two weeks prior to the site visit. Failure to do so may result in cancellation of the site visit.
a. If the Entity does not receive a site visit within the first year (12 months) from the accreditation approval date, the Entity's accreditation may be revoked.
Generally, the site visit will start at 8:00 am and last 6-8 hours. The length of the visit depends on the size of the facility, complexity of services provided, and type of program (sleep facility or independent sleep practice) and application being reviewed.
The AASM reserves the right to review any and all information at the time of any site visit. The site visitor has the right to be as detailed as necessary. A sleep facility should be fully prepared for review with all documents and data relative to all AASM standards during any site visit survey.
Remote Site Visit Process
AASM will view the sleep facility's physical space using remote video capability to ensure the sleep facility's physical space meets applicable AASM Standards for Accreditation. AASM will provide instructions for performing the remote site visit when scheduling the Special Circumstance site visit. The entity will be solely responsible for supplying the remote video tool (laptop, mobile phone, tablet) on the entity's end for completion of the site visit.
During the remote site visit, if the facility shows non-compliance to any of the current AASM Standards for Accreditation, AASM reserves the right to perform an on-site visit.
a. If on-site verification is required, AASM will bill the entity a flat fee of $2000* to cover the costs of another site visit. *Fee applies to the continental United States. Additional fees may apply for facilities
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located outside the continental United States. b. Payment must be made before the on-site site visit is scheduled.
Cancellation Policy/ Process
Cancellation of a scheduled site visit, for any reason, terminates and closes the application. The accreditation fee will not be refunded, and the entity's accreditation may be revoked if it has non-completion or failure of a site visit within the first year (12 months) of the accreditation approval date.
The AASM reserves the right to make exceptions to this policy when it deems warranted. The decision to make such an exception is at the sole discretion of the AASM. Such circumstances may include:
· catastrophic weather or environmental emergencies · unexpected injury or death of a key sleep facility staff member · other similar situations beyond the control of either the sleep facility/practice or the
AASM
Regardless of cause for cancellation, the entity will be required to pay all cancellation and rebooking fees as well as a $750 onsite site visit cancellation fee or $250 remote site visit cancellation fee respectively. The AASM will invoice the facility for this fee, which must be paid prior to rescheduling of the site visit. If the entity's accreditation is revoked and the entity reapplies, the application with applicable fee must be submitted, and the accreditation process will begin again.
FINAL VERIFICATION PROCESS
Following the site visit, the site visitor submits a report to AASM for review. Upon review of the site visit report, the entity will advance in one of three ways:
a. The site visit report indicates the entity is in substantial compliance with the AASM Standards for Accreditation. i. Result: The entity will continue with accreditation from the original date of accreditation by the AASM Accreditation Committee.
b. The site visit report indicates the entity is in compliance with the Standards, pending compliance to non-mandatory provisos identified during the visit. i. Result: The entity will receive accreditation with accreditation flag and has three (3) months to demonstrate all provisos have been resolved. If resolved, the entity will continue with accreditation from the original date of accreditation by the AASM Accreditation Committee.
c. The site visit report indicates the entity is not in compliance with the Standards for Accreditation and will receive a revocation of accreditation from the AASM Accreditation Committee. i. The Entity may apply, submit all applicable fees and begin the accreditation process again. 14

Submission of Information in Response to Provisos
Entities will maintain an Accreditation Flag until compliance is demonstrated to provisos. The deadline for submitting information regarding correction of deficiencies described in the provisos is three (3) months from the notification date stated by the AASM.
1. If the information is approved, the provisory designation is lifted. 2. If written information addressing the provisos is not received within three (3) months,
the review process is terminated, and accreditation is revoked.
The Accreditation Committee will decide if a site visit verifying compliance with provisos is necessary.
a. If a site visit to verify compliance with provisos is required, AASM will bill the entity a flat fee of $2000* to cover the costs of another site visit. *Fee applies to the continental United States. Additional fees may apply for facilities located outside the continental United States.
b. Payment must be made before the second site visit is scheduled. c. Once the entity demonstrates compliance to the provisos, the Provisory Designation is
lifted.
WITHDRAWALS
An entity may withdraw their application for accreditation at any time. In order to withdraw, the facility director must submit a letter, on the facility's letterhead, requesting the withdrawal. A portion of the accreditation fee will be refunded to the entity, the amount of which will be determined based upon the status of the application at the time of withdrawal.
Withdrawn prior to the completion of application review: · 80% of application fee will be refunded.
Withdrawn after initial review is complete: · $1,000 will be refunded.
If a decision regarding accreditation status has been made by the Accreditation Committee: · No refund will be given.
SPECIAL CONSIDERATIONS
An entity must notify the AASM within 30 days of the following changes within the facility or program: change of Facility Director or Principal Medical Staff Member, name or ownership, expansion or relocation. If two or more accredited sleep facilities merge, accreditation continues until the earlier scheduled expiration date. Following notification, the entity will follow the Application Review Process. These changes will require submission of appropriate documents and credentials for approval. Below is a listing of required documentation for each category.
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Change of Facility Director
Submit the following for the new facility director: · Copy of medical license (or other appropriate professional license) for all states where patients are seen. · Copy of Board-Certification from the American Board of Sleep Medicine (ABSM), a member board of the American Board of Medical Specialties (ABMS) or a member board of the American Osteopathic Association (AOA); or copy of fellowship certification with acceptance letter from a member board of the ABMS or a member board of the AOA to sit for the certification examination in sleep medicine. · Evidence of 30 AMA PRA Category 1 continuing medical education (CME) credits earned in sleep medicine within the past 36 months.
Expansion of the Sleep Facility
Expansion is defined as addition of new bedrooms to the existing facility or new populations to be served, such as pediatric patients.
1. If expanding number of testing bedrooms, submit the following: · A notification letter from the facility director on facility's letterhead indicating the effective date of the expansion, number of beds and new staff names (if applicable). · Photos of the new sleep bedrooms and bathrooms (if applicable), demonstrating compliance with applicable standards. · An 8 ½ by 11 floor plan of the facility, including room dimensions for each sleep bedroom, bathroom and the control room. The plan should also indicate which room(s) are handicap accessible. · For new technical staff personnel: o RST, RPSGT or RRT certification and licenses (if applicable). o Evidence of 30 CE credits earned in sleep-related topics within the past 36 months or Technical Staff continuing education credit (CEC) policy. o Valid CPR certification.
2. If adding a new population to be served, such as pediatric patients, submit the following: · A notification letter from the facility director on facility's letterhead indicating the effective date and the newly defined acceptable patient age range. · Age specific protocols for comprehensive polysomnography, titration of positive pressure therapy (both CPAP and Bi-level), and capnography.
Change of Control/Ownership of the Facility/Program
Change of control/ownership of the facility/program would include sale, acquisition or merger of the facility/program with the location of the facility staying the same. The following would need to be submitted:
· An official notification letter on the entity's letterhead signed by the seller (previous owner) notifying the AASM of the change (include effective date).
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· An official notification letter signed by the new owner notifying the AASM of the change (include effective date).
· An official letter signed by the facility director attesting that the sleep facility will continue to operate under current policies and procedures and remain in full compliance with Standards for Accreditation, Independent Sleep Practice Standards for Accreditation or DME Accreditation Standards.
· If new policies and/or procedures are implemented under new ownership, submission of those policies and procedures to the AASM for review.
Change of Primary Contact
· Notification either on facility letterhead or from an official facility email account from either the Facility Director or the outgoing primary contact, indicating the primary contact change and the effective date.
· The names of the outgoing primary contact and the new primary contact. · The new primary contact's title, email address, and direct contact phone number.
Relocation
Relocation is defined as move to a new location or new physical space within the same location. In case of relocation, the facility/independent sleep practice must submit a Special Circumstance Application to continue accreditation in the new location. A Special Circumstance Application is available on request only. An AASM Accreditation Coordinator will open an electronic application for an accredited facility upon submission of an official notification letter signed by the Facility Director. Information included in the facility's previous application will be included in the open Special Circumstance Application.
DME supplier do not require a special circumstances application for relocation.
The DME Supplier must submit: · An official letter signed by the medical director or authorized official on the DME supplier's letterhead (including the new address) notifying AASM of the change (including effective date). · Official letter must attest the DME supplier will continue to operate under current policies and procedures and remain in full compliance with DME Supplier Accreditation Standards. · If new policies and/or procedures are implemented as a result of the relocation, submission of those policies and procedures to the AASM for review.
If the facility relocates during the accreditation term, all parties involved must notify AASM via official letter within 30 days of the change. Upon notification, the following will occur:
· The facility will receive an extension of accreditation for 90 days. The entity has 90 days to submit the Special Circumstance Application and $1,000 Special Circumstance Application Fee from the date the electronic application was opened by AASM staff.
· Facilities may either submit a Special Circumstance Application or apply for Early Reaccreditation (if applicable). o A request for early reaccreditation must be reviewed and approved by the AASM. If the early reaccreditation option is approved, all regular
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reaccreditation fees will apply, and a complete application must be submitted. o Early reaccreditation will require an on-site visit. o The entity has 90 days to submit the early reaccreditation application.
If a Special Circumstance Application is submitted, the AASM will review the information provided and proceed with scheduling a remote site visit.
AASM reserves the right to perform a site visit at any time when it deems warranted.
Failure to notify the AASM of changes to a Special Consideration is cause for denial of future accreditation.
The accreditation granted by AASM will remain with the sleep entity (as designated by the facility's NPI Number). Facility NPI Number (Type 2) and legal ownership of the entity must be specified at the time of application for accreditation.
AASM accreditation is owned solely by the AASM. It is not saleable. AASM accreditation is a voluntary activity.
Relocation in Conjunction with an Ownership Change
If an entity relocates and changes ownership, this will be considered a new entity. The entity must reapply as a new entity.
RECONSIDERATION PROCESS
Accreditation of any facility/practice may be denied or revoked at any time for cause. Examples of cause include, but are not limited to:
· Illegal activity. · Incomplete or inadequate application. · Non-completion or failure of a site visit. · AASM Board of Directors action. · Violation of mandatory standards. · Facility Director changes, ownership changes, or relocation without timely notification
to AASM. · The sleep facility fails to notify the AASM within 30 days of initiation of any
government, local, state or federal investigation or adverse action taken against the facility that impacts the ability to meet any standards. · Non-compliance to provisos.
Only the Accreditation Committee can approve, deny, suspend, or revoke accreditation status. Entities may appeal a denial or revocation.
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The reconsideration process is described below: · The facility director will be notified by mail whenever accreditation is denied or revoked. · If the entity wishes to have the decision reconsidered, a request must be submitted in writing by the Facility Director within thirty (30) calendar days of the date of the letter of denial along with payment of $300. The submitted request for reconsideration should include documentation addressing the reasons for the denial/suspension/revocation. · The letter for reconsideration will be reviewed initially by the AASM Director of Accreditation and by the AASM Executive Committee or AASM Board of Directors. · The AASM Executive Committee or Board of Directors' decision will be sent to the entity within twelve (12) weeks of receipt of the reconsideration request letter. · The decision by the AASM Executive Committee or Board of Directors is final.
The cost to file a request for reconsideration is $300. Payment must accompany the Facility Director's letter. If payment is not received, the reconsideration request will automatically be rejected. All other costs associated with the reconsideration request are the responsibility of the sleep entity. This may include costs associated with a site visit.
LOGO USAGE AND ADVERTISEMENT OF ACCREDITED STATUS
Each fully accredited facility/practice may advertise that it is accredited by the American Academy of Sleep Medicine (AASM). Indication of accreditation by the AASM may be made in text only, unless the accredited sleep facility becomes a facility member of the AASM, in which case an accredited facility member logo is available for use.
Facility membership is available to sleep facilities and independent sleep practices and is voluntary and separate from accreditation.
Information on AASM membership for accredited sleep facilities is available at www.aasm.org. A directory of AASM member facilities indicating their sleep facility accreditation status is available at www.sleepeducation.org.
Use of any AASM logo other than the AASM Accredited Member Facility logo is strictly prohibited. The logo may be used only by accredited member facilities that have earned this right. You must be given permission or consent to use the AASM Accredited Member Facility Logo.
An accredited sleep facility that is not an AASM member facility may not use the AASM logo in conjunction with its facility in any way. A warning will be given if a sleep facility is found to misrepresent itself, or any other facility that is operated in conjunction with an accredited facility but is not itself accredited, by using the AASM logo. A sleep facility that continues to misuse the logo is subject to legal action including revocation of accreditation and a fine of $1,000 per offense.
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