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Accreditation of Sleep Disorders Centers

Process and Policies

Policies Revised March 2013

APPLICATION GUIDE FOR AASM ACCREDITATION OF SLEEP CENTERS FOR SLEEP RELATED DISORDERS HISTORY OF AASM ACCREDITATION The first sleep facility 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) writes and maintains the Standards for Accreditation. 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. OVERVIEW OF THE AASM ACCREDITATION PROGRAM AASM accreditation is a voluntary activity, providing recognition that a center meets rigorous standards set forth by the AASM. The AASM accredits sleep disorders centers. A sleep disorders center provides clinical diagnostic and treatment services for patients with sleep disorders. 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 center. The application period can take up to nine months. The Accreditation Committee oversees the accreditation process. Site visitors are board certified sleep specialists who are or have been directors of AASM accredited sleep facilities.

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CATEGORIES OF ACCREDITATION Provisional Accreditation Provisional accreditation is available to new, start-up centers, and new facilities opened by an existing center. It is only available to centers that have been open for a period of six months or less. Provisional accreditation is granted for a period of six months. (See Appendix A for required documents). An application for full accreditation must be submitted within six months of the date of provisional accreditation. Provisional to Full Accreditation An application for full accreditation must be submitted within six months from the date the provisional accreditation was granted in order to continue the accreditation. The center must be open and seeing patients for a period of 6 months to assure all information relative to the Full Accreditation is available to be evaluated. If an application for full accreditation is submitted within the six-month timeframe, provisional accreditation will continue through the review and site visit process. New Accreditation New accreditation is granted for five years from the date of approval by the Board of Directors. To apply for new accreditation the center must be in operation no less than 6 months. (See Appendix B for required documents) Reaccreditation An accredited center must complete a new application prior to the end of the accreditation term in order to achieve continued reaccreditation without delay or lapse in status. Reaccreditation applications are due 6 months prior to the center's accreditation expiration date. Applications for reaccreditation will not be accepted more than 10 months in advance of the expiration date. Out of Center Sleep Testing Accreditation The AASM Standards for Out of Center Sleep Testing for Adult Patients were developed for the primary purpose of ensuring that the highest quality of care is delivered to patients suffering from sleep-related illness. OCST accreditation is available to sleep centers providing home sleep testing. Areas in which a center must demonstrate compliance include:

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· · · · · · · ·

Patient Policies Facility and Equipment Practice Standards and Procedures Data Acquisition, Scoring and Report Patient Evaluation and Care Patient Records Quality Assurance and Quality Improvement And More

AASM Accreditation for Out of Center Sleep Testing in Adult Patients is granted to sleep centers that demonstrate compliance with all of the AASM Standards for Out of Center Sleep Testing in Adult Patients. This process includes the completion of an accreditation application and supporting documentation, a site visit, and approval. The OCST accreditation is granted for five years. An OCST accredited center must complete a new application prior to the end of the accreditation term in order to achieve continued reaccreditation without delay or lapse in status. The OCST application for independent entities is no longer available. If a center is already accredited and is performing Out of Center Sleep Testing, the OCST accreditation must be attained. Operation of OCST without an accredited status will jeopardize the sleep center's current accreditation. Application Sleep centers seeking AASM Accreditation for Out of Center Sleep Testing in Adult Patients must complete the Application for Sleep Center Accreditation. The application contains two sections (Sleep Center and OCST). Applicants are also required to submit supporting documentation including staff information, policies and procedures, and any reports related to a review of the center's OCST program. Applicants should follow a combined application and upload documents for both the sleep center and OCST accreditation in designated sections of the application. After submission of the combined (sleep center and OCST) application, the accreditation process explained in this document is the same for both types of accreditation. Policies and procedures specific to out of center sleep testing will be reviewed along with the sleep center accreditation application. Provisional accreditation does not include the OCST component. Centers not performing the OCST accreditation may skip the OCST section of the combined application.

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OCST Attestation Centers already accredited that plan or have already begun offering Out of Center Sleep Testing may fill out an attestation signed by the medical director and submit it along with a payment of $250. The attestation is a written statement assuring the AASM that the center will abide by the AASM OCST Standards and Guidelines. Once the attestation and payment are received, the center will be issued a verification letter adding the OCST accreditation to its existing operation. The sleep center accreditation number will remain the same and the add-on OCST accreditation will expire at the same time the main sleep center accreditation expires. At the time of reaccreditation all centers that have attained the OCST accreditation through the attestation option will be required to fill out the combined application and submit policies and procedures for both the sleep center and OCST operations. Should a site visit be required, both operations will be evaluated during one site visit. Accredited centers are required to follow the current OCST Standards for Accreditation and create a separate set of policies and procedures for home sleep testing. The attestation option will not be available to centers that failed the OCST site visit resulting in denial of OCST accreditation by the Board of Directors. To request a customized attestation form and invoice (available only to already accredited centers wishing to add OCST to its existing accreditation) send an email to Accreditation Department entitled "OCST Attestation" at [email protected] ACCREDITATION STATUS Accreditation without Provisos Accreditation without provisos is granted by the Board of Directors for five years from the date of approval to sleep centers that demonstrated compliance with all the Standards for Accreditation. Centers will receive an accreditation certificate in the mail. Accreditation with Provisos Accreditation with provisos is granted by the Board of Directors if the sleep center does not satisfactorily meet all of the Standards for Accreditation, but the Board

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believes that the center will be able to meet the Standards within three months of notification by the AASM, and will be able to operate safely in the interim. Compliance with requirements described in the provisos must be communicated in writing to the AASM. Denied Accreditation Centers that receive one mandatory proviso or more than 13 non-mandatory provisos will be denied accreditation. Appeals process is available to centers that did not fulfill the accreditation requirements resulting in denial of accreditation. A facility may apply for accreditation again at any time after denial. Revoked Accreditation If a center is not in substantial compliance with the Standards for Accreditation, the accreditation may be revoked. Examples of cause include but are not limited to: a. b. c. d. e. Illegal activity, Incomplete or inadequate application, AASM Board of Directors action, Violation of mandatory standards, Failure to notify the AASM within 30 days of initiation of any government investigation or adverse action taken against the facility that impacts the ability to meet any standards.

If accreditation is revoked, the center is required to wait one full year before applying for accreditation. Rescinded Accreditation If an accredited sleep center loses its ability to meet the Standards for Accreditation, e.g. loss of medical director or board certified sleep specialist, the Accreditation Committee may recommend to the Board of Directors that the center accreditation status be rescinded until the center again meets the Standards for Accreditation. While accreditation is rescinded, the sleep center is not accredited. The center may not use the AASM member center logo, or other materials that imply accreditation by the AASM. All references to AASM accreditation in advertisements must cease.

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In order for accreditation to be reinstated, the medical director must provide written documentation of changes that have been made to correct deficiencies. A site visit may be necessary, at the sleep center's expense, to determine whether the center now meets the Standards for Accreditation. 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 center is ready to resume its operations in full compliance with the Standards of Accreditation. Rescinded 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 center that may lead to rescinded accreditation is cause for denial of future accreditation. APPLICATION SUBMISSION PROCESS It is recommended that you visit the accreditation link at www.aasmnet.org for Frequently Asked Questions (FAQs), review of the accreditation process, and the most current Standards for Accreditation. Please follow these steps in the application process: 1. Read the Application Guide completely before beginning the online application forms or gathering supporting materials. 2. Decide if you are applying for provisional accreditation, or new. Review Categories of Accreditation for more information. (Review the Appendixes for the full list of documents required) 3. Fill out the online Application for Accreditation. 4. Assess your center using the Standards Self-Assessment. Check each box in the Standards Self-Assessment indicating that you meet or do not meet each standard. If you are applying for provisional accreditation, mark the appropriate boxes. 5. Collect supporting documents and materials. 6. Upload the materials to your online application. Review the Index for the comprehensive list of documents required for each application (Provisional and New). 7. Submit your online application to AASM along with payment to begin review.

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ACCREDITATION APPLICATION PAYMENT The AASM reviews all applications using the most current Application and Standards of Accreditation regardless of the age of the application submitted. The current Application for Accreditation is always available for free download at www.aasmnet.org. Separate applications must be submitted for each center seeking accreditation. Each center must be capable of operating independently. The AASM does not provide accreditation of satellite centers. Independent laboratories that conduct testing only are no longer accredited by the AASM The center's designated staff member and/or the medical director completes the on line application, medical director attests to the accuracy of the information and submits it with the accreditation fee to the national office. Fees New ­Full accreditation: $4500 (this fee covers the sleep center and OCST accreditation including one site visit for both on the same day) Provisional accreditation: $4500 (non-refundable) Reaccreditation: $4500 for an AASM member center and $7200 for a non-AASM member center.

* Sleep centers providing OCST services in more than one state are required to pay additional fees outlined in the table below.

Type of Facility New sleep center with one state Two to 10 states 11 or more states Previously accredited sleep center undergoing reaccreditation with OCST (one state only) Two to 10 states 11 or more states Application Fee Initial $4,500 $1000 for each additional state $500 per additional state $4,500 for member centers $7,200 for non-member centers $1000 for each additional state $500 per additional state

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**Please note that fees are subject to change without notice. Once the center's payment is received the AASM coordinator will email a receipt of payment to the designated primary contact. APPLICATION REVIEW PROCESS The entire online application goes through a full review by the RN Accreditation Reviewer to evaluate and assess all submitted documentation, materials and forms to determine compliance to the standards. Review of the online application typically takes from 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 review process will cease and the application will be removed from the AASM online system. a. The center may be asked to submit additional information regarding the standards. Issues that need clarification or additional information to determine compliance to the standards will be referred to as queries and communicated to the center primary contact via email. PLEASE ENSURE THAT YOUR SPAM FILTERS DO NOT BLOCK MESSAGES FROM AASM. b. The medical director/designated center staff member is required to respond to the queries via the online application within 14 calendar days from the e-mail receipt received by the applicant. c. Applicants who do not respond within 14 calendar days will be assessed a late fee of $500. d. If a response to the queries is not received within 28 days, the application is voided. i. ii. $1000 will be refunded to facilities applying for new accreditation and reaccreditation. After this, the center must submit a new application along with full accreditation fee payment. The $1000 refund does not apply to facilities applying for provisional accreditation or those moving from provisional to full accreditation.

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e. The AASM reserves the right to return incomplete applications.

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f. If the application does not pass the review process, the center will be notified that the application has been rejected. $1000 will be refunded. g. The fee for provisional accreditation is non-refundable. No refund will be provided should a facility fail to submit a full accreditation application within the appropriate timeframe. h. The medical director may appeal the decision of the reviewer in writing to the AASM Board of Directors within thirty (30) days of notification by AASM (See APPEALS PROCESS). New or Full Application Review Mandatory Standard Response: If the center is not in compliance with one or more of the mandatory standards, centers will be asked to submit additional information to substantiate compliance; this is called a query request. Additional information relative to mandatory standards only must be resolved prior to the scheduling of the site visit. The center has fourteen (14) days to respond to the request. Once the information is received, reviewed and compliance established, the center's site visit will be scheduled. Non-Mandatory Standard Response: The list of queries needing additional information or clarification related to nonmandatory standards will be emailed at the same time the mandatory queries are sent. Centers will have until the date of the site visit to resolve issues and make revisions to policies or procedures reflected in the non-mandatory standards. The site visitor will determine compliance with non-mandatory standards on-site during site visit. Failure to satisfy all mandatory standards will prevent, or delay the site visit and ultimately may result in denial of accreditation. Reaccreditation Application Review

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Applications must be received no later than six (6) months prior to the expiration date of the current accreditation term. Centers failing to do so may still submit an application up to the actual expiration date; however, late fees of $500 - $1,500 will be assessed depending on the lateness of submission. Facilities failing to submit their reaccreditation application at least six months prior to their accreditation expiration date will be subject to the following late fees: · Application submitted 179-150 days prior to expiration: $500 · Application submitted 149-120 days prior to expiration: $1000 · Application submitted 119 days prior to expiration: $1500 Centers failing to submit the reaccreditation application by the expiration date will be required to submit new accreditation application. The original accreditation date will be lost and a site visit will be required. Centers will experience lapse in accreditation status until new accreditation is approved. Early Reaccreditation Accredited centers that change owners or relocate less than 18 months before the accreditation expiration date may complete an early reaccreditation application. Early reaccreditation option is subject to the AASM approval. SITE VISIT PROCESS Once the New or Full application is completed in its entirety and all required documentation has been submitted and reviewed, the site visit will be scheduled. Please note a site visit is not required for Provisional Accreditation. A Business Associate Agreement must be signed by both parties prior to the site visit. If the agreement is not fully executed the site visit will be cancelled. Scheduling: Based on the site visitor's availability, a visit date will be selected by accreditation staff. The center will then be notified via email that a site visit has been scheduled and confirmed. The center will be offered one (1) date. If this date does not work with the center'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 and void the application.

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a. Requirements for the Site Visit The medical director, all staff physicians who interpret PSGs, a lead technologist and one additional technical staff must be present during the site visit. The center'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 Accreditation Department at least two weeks prior to the site visit. Failure to do so may result in cancellation of the site visit. Generally, the site visit will start at 8:00 am and last 4-6 hours. The length of the visit depends on the size of the facility, complexity of services provided and types of programs (sleep center and/or OCST) being reviewed. Facilities should NEVER contact their site visitor directly; all communication is to be directed through the AASM coordinator assigned to the center. Site visitors are not allowed to receive any gifts, promotional items or any other monetary remuneration from the center. b. Cancellation Policy/ Process Cancellation of a scheduled site visit, for any reason, renders the center's application null and void. The accreditation fee will not be refunded. 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 center staff member, OR · other similar situations beyond the control of either the sleep center or the AASM. Regardless of cause for cancellation, the center will be required to pay all cancellation fees and re-booking fees. If the center reapplies, the application with applicable fee must be submitted and the accreditation process will begin again. 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 center should be fully prepared for review with all documents and data relative to all AASM standards during any site visit survey.

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APPROVAL PROCESS Following the site visit, the site visitor submits a report/s to the Accreditation Committee for review. Each type of accreditation (sleep center and/or OCST) receives a separate report based on the most current Standards for Accreditation. A recommendation regarding accreditation status is submitted to the AASM Board of Directors for final approval. The Board of Directors will render one of three decisions: a. If the Board of Directors approves accreditation without reservation, the sleep center is granted full accreditation for five (5) years from the date of approval by the board. If the Board of Directors finds a sleep center is generally, but not fully in compliance with the Standards, accreditation will be granted pending compliance to the non-mandatory provisos for a period of five years. Failure to meet one or more mandatory standards will always result in denial of accreditation. No exceptions will be made. i. A non-mandatory proviso must be met within three (3) months of the notification date stated by the AASM. c. If the Board of Directors denies the sleep center and/or OCST accreditation, the center may reapply, submit all applicable fees and begin the accreditation process again.

b.

The medical director of a sleep center that is denied accreditation has the right to appeal in writing to the AASM Board of Directors (see APPEALS PROCESS). Submission of Information in Response 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. a. If the information is approved, the provisos are lifted and full accreditation granted from the date of approval by the Board of Directors. b. If written information addressing the provisos is not received within three (3) months, the review process is terminated and accreditation may be denied.

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The Accreditation Committee will decide if on-site verification of compliance with provisos is necessary. a. If on-site verification is required, AASM will bill the center a flat fee of $1600 to cover the costs of another site visit. b. Payment must be made before the second site visit is scheduled. c. Once the center meets the Standards for Accreditation, it will be granted full accreditation for five (5) years from the date of approval by the Board of Directors. WITHDRAWALS A center may withdraw their application for accreditation at any time. In order to withdraw, the medical director must send a letter, on sleep center's letterhead, requesting the withdrawal. A portion of the accreditation fee will be refunded to the center, 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: · $800 administrative fee will be withheld. Withdrawn after initial review is complete: · $1,000 will be refunded. If a site visit has already been scheduled: · no refund will be given. SPECIAL CONSIDERATIONS A sleep center must notify the AASM within 30 days of any change within the sleep center. A change of Medical Director, Sleep Specialist, expansion or ownership will require submission of appropriate documents and credentials for approval. Below is a listing of required documentation for each category. Change of Medical Director: · Copy of medical license for all states where patients are seen, · Associated Sleep Facilities Form, · Copy of Board Certification from the ABMS, ABSM, AOA, OR · Copy of fellowship certification with acceptance letter from the ABMS, ABSM, or AOA to sit for the certification examination in sleep medicine,

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· CME tracking log with evidence of 30 AMA PRA Category 1 CMEs earned in sleep medicine within the past 36 months. Change of Sleep Specialist · Associated Sleep Facilities Form, · CME tracking log with evidence of 30 AMA PRA Category 1 CMEs earned in sleep medicine within the past 36 months, · Copy of Board Certification from the ABMS, ABSM, AOA, OR · Copy of fellowship certification with acceptance letter from the ABMS, ABSM, or AOA to sit for the certification examination in sleep medicine. Expansion of the Sleep Center Expansion is defined as addition of new bedrooms to the existing center 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 medical director on facility's letterhead indicating the effective date of the expansion, number of beds and new staff names (if applicable), · Four to eight photos of the new sleep bedrooms and bathrooms (if applicable), · 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 staff personnel o RST, RPSGT or RRT certification and licenses (if applicable) o CE tracking log with evidence of 30 CE credits earned in sleep medicine or sleep technology within the past 36 months. 2. If adding a new population to be served such as pediatric patients, submit the following: · A notification letter from the medical 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.

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Change of Control/Ownership of the Sleep Center Including Sale, Acquisition or Merger (location of the center stays the same) · An official notification letter on the center's letterhead signed by the owner notifying AASM of the change (include effective date), · An official letter signed by the medical director attesting that the sleep center will continue to operate under current policies and procedures and remain in full compliance with AASM Standards for Accreditation of Sleep Disorders Centers, · If new policies and/or procedures are implemented under new ownership submission of those policies and procedures to the AASM for review. AASM reserves the right to perform a site visit at any time when it deems warranted. Relocation In case of relocation the facility must submit a special circumstance application. Relocation is defined as move to a new location or new physical space within the same location. SPECIAL CIRCUMSTANCE APPLICATION Special circumstance application is available on request only. An accreditation coordinator opens up an electronic application for an accredited facility upon submission of an official notification letter signed by the medical director or owner. See Appendix C for a list of materials required in the application. CHANGE NOTIFICATION GUIDELINES AASM accreditation is owned solely by the AASM. It is neither saleable nor transferable. AASM accreditation is a voluntary activity. Failure to notify the AASM of changes in an accredited center that may lead to special circumstances reapplication is cause for denial of future accreditation. The accreditation granted by AASM will remain with the person/entity holding legal ownership of the sleep center. Legal ownership of the center must be specified at the time of application for accreditation.

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If any changes explained above occur during the accreditation term, all parties involved must notify AASM in writing within 30 days of the change. Upon notification, the following will occur: · The centers involved will receive an extension of accreditation for 90 days. · Centers may either apply for Early Reaccreditation OR submit a Special Circumstance application. If early reaccreditation option is approved all regular reaccreditation fees will apply and a complete application must be submitted. If a Special Circumstance application is submitted the AASM will review the information provided and proceed with a site visit scheduling. Sleep centers that submit a special circumstance application due to relocation will require a site visit. · The cost of site visit will be assumed by the sleep center. · AASM will bill the center a flat fee of $1600 to cover the cost of the site visit. · Payment must be made before the site visit is scheduled. · The 90-day grace period of accreditation will be extended if AASM is unable to complete the site visit within 90 days. · The Board of Directors determines accreditation status after the site visit. Accreditation, if approved, will be granted for the remainder of the original accreditation term. If two or more accredited sleep facilities merge, accreditation continues until the earlier scheduled expiration date. APPEALS PROCESS Accreditation of a sleep disorders center 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, site visit failure, AASM Board of Directors action, violation of mandatory standards,

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Medical director, sleep specialist, 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.

Only the AASM Board of Directors can approve, deny, rescind, or revoke accreditation status. Facilities may appeal a denial or revocation. The appeal process must abide by the following guidelines: · The medical director of the sleep center will be notified by mail whenever accreditation is denied or revoked. · If the center wishes to appeal the decision, a request must be submitted in writing by the medical director of the sleep center within thirty (30) calendar days of the date of the letter of denial along with payment of $300. · The letter of appeal will be reviewed initially by the AASM Director of Accreditation, followed by the Accreditation Committee, and finally by the Board of Directors. · The Board's decision will be sent to the medical director of the sleep center within twelve (12) weeks of receipt of the appeal letter. · The decision by the Board of Directors is final. The cost to file an appeal is $300. Payment must accompany the medical director's letter. If payment is not received, the appeal will automatically be rejected. All other costs associated with the appeal are the responsibility of the sleep disorders center. Such costs could include a site visit. LOGO USAGE AND ADVERTISEMENT OF ACCREDITED STATUS Each fully accredited sleep center 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 center becomes a center member of the AASM, in which case a member center logo is available for use. Membership is voluntary and is separate from accreditation.

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Information on AASM membership for accredited sleep facilities is available at www.aasmnet.org. List of member centers indicating their sleep center and OCST accreditation status (if applicable) is available at www.sleepeducation.com. Use of any AASM logo other than the AASM Accredited Member Center Logo is strictly prohibited. The logo may be used by accredited member centers that have earned this right. You must be given permission or consent in order to use the AASM Accredited Member Center Logo. An accredited sleep center that is not an AASM member center may not use the AASM logo in conjunction with its center in any way. A warning will be given if a sleep center is found to misrepresent itself, or any other center that is operated in conjunction with an accredited center but is not itself accredited, by using the AASM logo. A sleep center that continues to misuse the logo is subject to legal action including revocation of accreditation and a fine of $1000 per offense.

Appendices A, B and C are below (pages 20-24).

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Appendix A Documents Required for Provisional Accreditation

The following application materials must be completed and submitted in the on line application for review: Reporting of patient data is not required; however, policies and procedures are required relative to the elements of the standard 1. Business Associate Agreement a. Signed by the facility authorized representative

2. Facility License: Standard A-1 (photocopies are acceptable) a. Facility License; b. Certificate of Occupancy and/or Building Permit c. Attestation signed by medical director if not required by state or law 3. Personnel: Standards B 1-11 (photocopies are acceptable) a. Medical Director Current Medical License i. Valid in the state of the facility and in all states in which patients are seen b. Designated Sleep Specialist: Boarded Sleep Certification certificate c. Technical Staff: certificate and or registration/license from one of the following organizations i. BRPT ii. ABSM iii. NBRC d. Completed Continuing Education Professional and/or Technical Tracking log for: i. Medical Director/Sleep Specialist: Earned in sleep medicine ii. Technical Staff: Earned in sleep related topics e. Training information in polysomnography for each non-registered sleep technician i. Evidence of enrollment in or completion of either the A-STEP SelfStudy module or CAHEEP accredited program ( Enrollment Form) ii. Evidence of completion of at least one A-STEP module f. Confirmation of CPR certification i. Evidence of both cognitive and skills testing ii. Assure CPR card is signed by card holder with expiration date g. Job Descriptions for all professional and technical staff 4. Sleep Facility Letterhead 5. Copy of Floor Plan a. 8 ½" x 11" with legible dimensions of length and width for all rooms b. Identify purpose of each room (i.e. testing room, control room) Sleep Center and OCST Accreditation Policies and Process March 2013. 20

c. Include handicap accessibility d. Photographs i. If the facility is open, include a photo of each testing room showing space on each side of the bed to accommodate ER personnel; ii. Handicap accessible bathroom is to show toilet and grab bars iii. Control room iv. Front of building to include signage and access through doors and hallways. 6. Advertising Material a. Brochure if applicable or; b. Confirm advertising does not occur 7. Policies, Procedures Protocols a. Section C 1-2: Patient Policies i. Patient Acceptance ii. Direct Referral b. Section D 1-14: Facility and Equipment Management c. Section E (1-4): Protocols: Adult and Pediatric (if applicable) i. PSG, MSLT, MWT, PAP Titration, Split Night ii. All other protocols conducted at the facility d. Section F (6-7 ): Inter-scorer Reliability Policy i. Assure policy reflects all elements of standard even if using the AASM on line ISR program e. Section I (1-2): Emergency Plan i. Medical ii. Internal/external/environmental f. Section J (1): Quality Assurance Plan i. Assure listing of indicators identified to be monitored ii. Assure responsibilities of medical director/sleep specialist are defined g. Job Descriptions of all Professional and Technical Personnel

8. The Following Forms are to be submitted a. Associated Sleep Facilities Form ( for medical director and designated sleep specialist) b. Equipment List c. Patient Volume and Statistic Form ( if open assure completed; if not yet opened please provide with 0's in the sections) d. Self-Assessment Checklist

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Appendix B Documents Required for New or Full Accreditation

The following application materials must be completed and submitted in the on line application for review: Reporting of patient data for the previous 6 months prior to the date of application submission is required; 1. Business Associate Agreement a. Signed by the facility authorized representative 2. Facility License: Standard A-1 (photocopies are acceptable) a. Facility License; b. Certificate of Occupancy and/or Building Permit c. Attestation signed by medical director if not required by state or law 3. Personnel: Standards B 1-11 (photocopies are acceptable) a. Medical Director Current Medical License i. Valid in the state of the facility and in all states in which patients are seen b. Designated Sleep Specialist: Boarded Sleep Certification certificate c. Technical Staff: certificate and or registration/license from one of the following organizations i. BRPT ii. ABSM iii. NBRC d. Completed Continuing Education Professional and/or Technical Tracking log for: i. Medical Director/Sleep Specialist: Earned in sleep medicine ii. Technical Staff: Earned in sleep related topics e. Training information in polysomnography for each non-registered sleep technician i. Evidence of enrollment in or completion of either the A-STEP SelfStudy module or CAHEEP accredited program ( Enrollment Form) ii. Evidence of completion of at least one A-STEP module f. Confirmation of CPR certification i. Evidence of both cognitive and skills testing ii. Assure CPR card is signed by card holder with expiration date 4. Sleep Facility Letterhead 5. Copy of Floor Plan a. 8 ½" x 11" with legible dimensions of length and width for all rooms b. Identify purpose of each room (i.e. testing room, control room) c. Include handicap accessibility Sleep Center and OCST Accreditation Policies and Process March 2013. 22

6. Advertising Material a. Brochure if applicable or; b. Confirm advertising does not occur 7. Policies, Procedures Protocols a. Section C 1-2: Patient Policies i. Patient Acceptance ii. Direct Referral b. Section D 1-14: Facility and Equipment Management c. Section E (1-4): Protocols: Adult and Pediatric (if applicable) i. PSG, MSLT, MWT, PAP Titration, Split Night ii. All other protocols conducted at the facility d. Section F (6-7 ): Inter-scorer Reliability Policy i. Assure policy reflects all elements of standard even if using the AASM on line ISR program e. Section I (1-2): Emergency Plan i. Medical ii. Internal/external/environmental f. Section J (1): Quality Assurance Plan i. Assure listing of indicators identified to be monitored ii. Assure responsibilities of medical director/sleep specialist are defined iii. Most recent Quarterly report for all indicators selected to be monitored, signed by the medical director/sleep specialist iv. Quarterly ISR report should reflect the names of all scoring techs and the designated sleep specialist and show the detail comparison of all 4 parameters.

8. The Following Forms are to be submitted a. Associated Sleep Facilities Form ( for medical director and designated sleep specialist) b. Equipment List c. Patient Volume and Statistic Form (numbers of patients evaluated, tests performed, diagnoses for the 6 months prior to the date of application submission) d. Self-Assessment Checklist

Sleep Center and OCST Accreditation Policies and Process March 2013.

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Appendix C Document Required for Special Circumstance Application

The following application materials must be completed and submitted in the on line application for review: 1. Business Associate Agreement a. Signed by the facility authorized representative 2. Facility License b. Building permit, certificate of occupancy indicating compliance to local law and regulation to operate as a health care provider Copy of floor plan for new location Appropriate Staff Credentials a. Professional Staff i. Medical Director license ii. Associated Sleep Facility Form iii. Copy of Board Certification in Sleep iv. If the medical director or sleep specialist are new since the last accreditation period: 1. Professional CME tracking log with 30 CMEs *Not required if no change in medical director b. Technical Staff i. Copies of all sleep technicians registrations/certifications 1. RPSGT, RST ii. Non-Registered Technicians 1. Evidence of training in sleep (A-STEP enrollment with completion of at least one module) iii. Copy of Certification in CPR (with skills training component) iv. If technical staff are new since the last accreditation period: 1. Continuing Education Tracking log with 30 CECs *Not required if no change since last accreditation Patient Volume Statistics Form Equipment List Policies and procedures that have changed with the move if applicable or a letter of attestation from the medical director stating there have been no changes in operation or policies and procedures with the move. a. There may be alterations necessary to the Emergency plans for internal and external emergencies.

3. 4.

5. 6. 7.

Sleep Center and OCST Accreditation Policies and Process March 2013.

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American Academy of Sleep Medicine 2510 North Frontage Road Darien, IL 60561-1511

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