Frequently Asked Questions

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Quality Assurance

For the Facility Quality Assurance program, facilities must have a QA program that addresses the following indicators:

  1. A process measure for OSA;
  2. An outcome measure for OSA;
  3. An outcome measure for another sleep disorder (e.g. RLS, Insomnia or Narcolepsy); and
  4. Inter-scorer reliability as outlined in Standard F-7.

For the HSAT Quality Assurance program, facilities must have a QA program that addresses the following indicators:

  1. Two (2) process measures
  2. One (1) outcome measure

For questions on specific measures, please contact the AASM Accreditation Department.  For more information regarding Quality Assurance, please review the AASM’s published Quality Measures.

Yes. The sleep facility can utilize the same indicators for both in-center and HSAT; however, it must be addressed within the QA policy.

The AASM Standards allow for the sleep lab and clinic to be in separate physical location. The AASM defines sleep facility as the sleep lab and clinic collectively, even if they are in separate physical locations. Regardless of the location of the clinic (i.e. within the center, in a physician’s separate office, etc.), it is considered part of the sleep facility and must provide information required for the sleep facility to meet these standards.

The Standards require that the sleep facility maintains all clinical information, including the PAP assessment data specifically required by Standard H-2 for applicable patients, and quality assurance data required by Standards J-1-J-3 for each patient seen or tested in their medical record. The AASM Standards do not specify the location where the medical records must be held (i.e. the clinic vs. the lab) but these records must be maintained and accessible by the sleep facility.

The sleep facility is not required to have this information for patients that are directly referred for testing only; Standard H-2 only applies to patients who are prescribed PAP by sleep facility staff.

The following strategies can be utilized to gain access to data that is needed to meet these standards:

  • The clinic and lab can have a Business Associate Agreement to address the sharing of PHI and share data with the lab accordingly.
  • The clinic can have patients give consent to sharing the data with the lab.
  • The clinic can provide the data needed to measure the QA indicators to the lab de-identified. This would address any HIPAA concerns the clinic may have.
  • The clinic can maintain the QA measures for clinic specific measures and report results to the lab for inclusion in the larger QA report.

It is important that the clinic understand that it is their responsibility, as clinic of the accredited sleep facility, to ensure that the facility as a whole is able to meet all accreditation standards.

Interpretation and Diagnosis

The Standards do not define who can interpret sleep studies. It is at the facility’s discretion to decide who may interpret; however, only licensed physicians, and APRNS in some states, may diagnose a medical condition, and all individuals must practice within the limits of their license or scope of practice. Standard F-8 requires diagnoses made by individuals not board-certified in sleep medicine be reviewed by an individual who is board certified in sleep medicine.

Yes; it must be indicated on the report that the diagnosis has been reviewed by the individual board certified in sleep medicine.

HSAT Requirements

Under the AASM Standards for Accreditation, all AASM-accredited sleep facilities must have the capability to conduct home sleep apnea testing (HSAT) as part of their sleep program. This includes developing HSAT policies and procedures, having access to a HSAT device, and having the ability to conduct HSAT when needed. Please note that your sleep facility can rent HSAT equipment or have an arrangement with a separate entity to access a HSAT device when needed.

The sleep facility has the option to contract home sleep apnea testing. Please see Standard F-9 – Subcontracting HSAT for additional information.

According to the AASM Practice Parameters, only patients 18 years or older should be tested using HSAT. If your sleep facility sees only patients 17 years of age or younger, you will not be required to maintain an HSAT program.

The AASM is not able to provide recommendations for programs that provide HSAT. It is the facility’s decision to choose a subcontracting company, provided that the subcontractor meets all applicable AASM HSAT Standard requirements.

Indicate within the application that the facility is subcontracting HSAT. The request for HSAT policies and procedures in the application will be determined based on the elements of HSAT that are subcontracted. Although the sleep facility is subcontracting their HSAT services, they will continue to be responsible for patient management, diagnosis, and reporting HSAT quality assurance. Subcontracted HSAT staff and the HSAT contract will not be requested within the application.

Subcontracting Scorers

Technologists scoring as part of a subcontracting company should not be listed within the application; however, they must still meet all applicable accreditation requirements as part of the subcontracting agreement. Minimally, the subcontracting scoring company will need to be identified.

Per Standard F-10, the facility is responsible for assessing the performance of the subcontractor in meeting contractual obligations including meeting applicable AASM Accreditation standards for scoring personnel (ex. Standard F-8 – Inter-scorer Reliability). Therefore, your written agreement with the subcontractor must enumerate the performance expectations of the subcontractor including adherence to application AASM Standards. The subcontracted scoring contract will not be requested in the application.

Miscellaneous Standards Questions

Per Standard B-13, each facility shall comply with all background check requirements which may be required by federal, state or local law. In the absence of such requirements, the facility shall conduct criminal background checks of all new employees. The facility shall utilize information obtained in this process only to the extent such information is relevant to the job duties of a particular person. Subcontracted employees who have patient interaction fall under this requirement.

Yes. Per Standard I-4, all facilities, at a minimum, must have either an automated external defibrillator (AED) or access to an on-site medical emergency response team (typically available in hospital-based facilities).

A sleep facility, as defined by the AASM, is composed of a laboratory (where patients are tested), and a clinic (where patient consultation and management is offered by medical staff members). Under Standard G-1, the facility must demonstrate management of an adequate range of sleep disorders.

The AASM does not accredit sleep labs or independent diagnosing testing facilities that only provide testing without availability for patient management (clinical services).

At least one member of the technical staff of the sleep facility must be registered by or accepted to sit for a registration examination by the:

  1. American Board of Sleep Medicine (ABSM)
  2. National Board for Respiratory Care (NBRC)
  3. Board of Registered Polysomnographic Technologists (BRPT)
  4. Another organization that offers an equivalent examination accepted by the AASM.

The registry exam must be passed within one year from acceptance to sit for the examination; otherwise, the individual will be considered a non-registered tech. The individual(s) fulfilling this standard must be present at the facility at least 30 hours per week (or 75% of operating hours).

The AASM Standards do not specify a dimension requirement for sleep testing bedrooms. However, each room must be single occupancy, private and comfortable, have hard floor-to-ceiling walls, and a privacy door that opens directly to a corridor or common use area. Patient testing bedrooms must not have any impediments to the delivery of emergency care.  The patient testing rooms must be of sufficient size to accommodate emergency personnel access with a minimum of 24 inches of available clear space on three sides of the bed, which must be at least a standard hospital bed.

For additional physical space requirements, please reference Standards D-5 through D-10.

Yes. All members of the technical staff, regardless of job duties, must be certified in CPR per Standard B-9.

Yes. Facilities that are undergoing any one or more of these significant changes, must contact the AASM in writing within one month of the change. Please contact the AASM Accreditation Department for further details or reference the Situations that Require Notification to the AASM Fact Sheet.

Facilities that are or have relocated must contact the AASM in writing within one month of the change. For all relocations, a facility must submit formal notification from the facility director and complete a special circumstance application within 90 days of the relocation notification. If centers are relocating within 18 months of their expiration date, they can choose to pursue an early reaccreditation application. Continued accreditation at the new location will be contingent on the AASM Board of Directors approval. Please reference Page 15 of the AASM Accreditation Process and Policies for further information on the Special Circumstances process.

If the facility is relocating and changing ownership simultaneously, the facility will be considered a new sleep facility and must submit a new application for accreditation. Please see the AASM Accreditation Process and Policies for more information.

We only request that the sleep facility update the AASM on a change of facility director or primary contact. All other professional or technical staff members must be updated at the time of reaccreditation. Please ensure these new members are adhering to the qualifications in the Standard B section included in the AASM Standards for Accreditation.

No, AASM accreditation is location specific. Your facility accreditation only applies to the address of the accredited center. For this reason, satellite labs or additional centers would not fall under your accreditation. Each location would need to obtain separate accreditation by submitting a new accreditation application.

Reaccreditation applications are opened 10 months prior to the expiration date. You must submit an application for reaccreditation of your sleep facility to maintain accreditation. Applications for reaccreditation are due 6 months prior to your expiration date. The AASM Accreditation Department will send official notices via mail 10 months and 7 months prior to your upcoming expiration date with information regarding reaccreditation processes. The facility can submit an application after the due date; however, a late fee will apply. If the facility fails to submit a reaccreditation application by the accreditation expiration date, the facility must pursue new accreditation by submitting a new online application via the AASM website. Please note that there are no extensions granted past the accreditation expiration date.

The AASM defines a direct referral as a patient that is tested by the facility but is not seen by facility professional staff prior to or after the test for follow-up. For example, if a patient comes to your facility for testing only and returns to their primary physician (not associated with your sleep facility) for follow-up and treatment, the patient would be considered a direct referral.

If a physician’s private practice is not associated with the sleep lab (i.e. not serving as the sleep clinic), these patients would not be included in the Patient Volume and Sleep Study Statistics section of the application. However, if the private practice directly refers patients to the sleep facility for testing, they would need to be included in Question 3 of the Patient Volume and Sleep Study Statistics section addressing direct referrals. To address specific circumstances, please contact the AASM Accreditation Department.

After the site visit, the sleep facility can expect their decision letter and site visit report within four to six weeks. The accreditation packet will be sent to the mailing address included in your file.

Clinics or practices that provide home sleep apnea testing but do not have a lab where overnight testing is performed qualify for our Independent Sleep Practice (ISP) Accreditation program.  Independent Sleep Practice programs must accept patients with all sleep disorders, provide ongoing patient management, and have a relationship with an AASM-accredited sleep facility that can provide overnight testing when needed. Please see the ISP Standards for Accreditation for more information.

Accreditation Process/Policies

Yes, an entity can utilize their personalized Business Associate Agreement. This would be considered a custom BAA that would need to be reviewed and approved by the AASM Director of Accreditation. This review process can take approximately 1-3 months to complete. The AASM Director of Accreditation will work directly with the facility regarding any information that needs to be included or omitted.

If the facility would like to submit their application prior to having an AASM signature on the custom BAA, we ask that you upload the document without signatures into the Business Associate Agreement section of the application. The AASM will work with your facility while in the application process to complete this agreement. Once the BAA has been approved and signed by both parties, the fully executed document will be uploaded into your application and emailed to the primary contact.

Per the AASM Standards for Accreditation, all technical staff are required to earn 10 credits in sleep related topics per year averaged over three years (i.e. 30 CECs earned over the last three years [36 months]); however, for a newly hired sleep technologist, the AASM may accept CECs prorated based on the hire date if the facility also submits a continuing education policy. The policy must indicate that the sleep program will prorate CECs based on the date of hire of technical staff and will adhere to Standard B-9 Sleep Technician and Technologist Continuing Education. For example, if a tech has been working at the sleep facility for only one year, the AASM will require 10 sleep-related CECs along with a continuing education policy to meet compliance.

The continuing education policy can be uploaded into the tech training policy in the application.

Yes, the AASM Accreditation Reference Manual available in either a digital or physical copy. This easy-to-use guide provides concrete examples of policies, procedures, forms and documents required per Accreditation Standards. These samples are provided to assist in customizing your policies and procedures according to the specific needs of your sleep facility. Tabbed sections enable you to quickly access the information needed.

Purchase your e-book or print copy of the AASM Reference Manual today! Although the same content, the e-book contains easily customizable electronic example policies, procedures, forms and reports.