Independent Sleep Practice Accreditation
Who Should Apply?
Independent Sleep Practice Accreditation is available to sleep practices that manage patients with all sleep disorders and conduct home sleep apnea testing (HSAT) but do not have a lab for in-center sleep studies. This program replaces the HSAT Stand-alone accreditation that was previously offered to similar practices.
Accreditation Fee | New Application
Reaccreditation Fee | Facility Member
Reaccreditation Fee | Non-Member Facility
Entities may be eligible for volume pricing. Visit the Accreditation Network webpage to learn more.
Join AASM membership and save on reaccreditation fees. AASM Facility Members also gain access to benefits including maintenance of accreditation, a listing on SleepEducation.org, discounts on training materials, and more. View full benefits and apply for independent sleep medicine practice accreditation today.
Independent Sleep Practice FAQs
Independent Sleep Practice Information
A practice that manages patients with all sleep disorders and conducts home sleep apnea testing (HSAT) but does not have a lab for in-center sleep studies.
Independent Sleep Practice Accreditation is $4,500 for a new application or an entity that is reaccrediting and has active membership. The reaccreditation fee for non-members is $7,200.
The accreditation term is granted for five years.
How long does it take to receive accreditation from the time my application is submitted? Is there a way to speed up review time?
In general, accreditation can take 3-4 months to complete from application submission to the AASM Accreditation Committee’s approval. The AASM offers an expedited option for an additional $500. The expedited review allows the application to be approved in an average of 1-2 months.
Our Independent Sleep Practice has only been operational for less than 6 months, which application type should I complete to obtain accreditation?
Independent Sleep Practices that have been operational less than 6 months, or not yet have opened, must complete a new accreditation application. Upon approval from the AASM Accreditation Committee, accreditation will be granted requiring a site visit to be completed within 12 months from the date of approval.
Six (6) months from the date of approval, the facility will be required to access their application and enter the previous 6 months patient volume and study statistics data, as well as one full quarter quality assurance report. Following the review of this information, the program will be contacted to schedule their site visit. The site visit must occur within 12 months from the date of approval.
You must apply for reaccreditation of your Independent Sleep Practice to maintain accreditation. Reaccreditation applications are opened 10 months prior to the expiration date. Applications for reaccreditation are due 6 months prior to the expiration date. The Accreditation Department will send notices 10 months and 7 months prior to the expiration date. The Independent Sleep Practice can apply after the due date; however, a late fee will apply. If the Independent Sleep Practice fails to submit a reaccreditation application by the accreditation expiration date, the Independent Sleep Practice must submit a new online application. Please note that there are no extensions granted past the accreditation expiration date.
Yes, the AASM Accreditation Reference Manual is available in either a digital or physical copy found on the Online Store. 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 Independent Sleep Practice. Tabbed sections enable you to quickly access the information needed.
I see patients at another practice not related to the Independent Sleep Practice. Do they count in the patient volume statistics form?
If a physician’s private practice is not associated with the Independent Sleep Practice (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 Independent Sleep Practice for testing, the total will need to be reported in the direct referral column. To address specific circumstances, please contact the AASM Accreditation Department.
When logged in to your AASM account, navigate to the “My Organizations” tab on the left-hand side of the page. At the bottom of this page, click on the “Manage Applications” link. This should route you to your past applications submitted with the AASM.
Accreditation Process and Policies
We only request that the Independent Sleep Practice update the AASM on a change of the Principal Medical Staff Member (board-certified physician) 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.
My program is relocating, changing principal medical staff members, changing primary contacts, changing ownership, or changing sleep program name. Am I required to contact the AASM?
Yes. Independent Sleep Practices that are undergoing one or more of these changes must submit a Special Considerations application within one month of the change. Please see Program Changes webpage on how to submit a Special Considerations application as well as the materials needed for submission.
When a sleep program relocates, the AASM requires accredited sleep programs to complete and submit a Special Circumstance Application within 90 days of relocation. The Special Circumstance Application allows the accreditation to be continued from your previous location to your new location of operations. To open the Special Circumstance Application, log-in to your AASM account and navigate to My Organizations. Please select “Request Change” under the Independent Sleep Practice relocating and select “Relocation” in the Special Consideration Change Request form. Once the application has been opened, update the information for each section pertinent to the new location.
If the Independent Sleep Practice is 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 Accreditation Committee’s approval. Please reference Page 15 of the AASM Accreditation Process and Policies for further information on the Special Circumstances process.
If the Independent Sleep Practice is relocating and changing ownership simultaneously, the practice will be considered a new practice and must submit a new application for accreditation. Please see the AASM Accreditation Process and Policies for more information.
No, AASM accreditation is location specific. Your Independent Sleep Practice accreditation only applies to the address of the sleep practice. For this reason, satellite practices would not fall under your accreditation. Each location would need to obtain separate accreditation by submitting a new accreditation application.
After the site visit, the Independent Sleep Practice 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. Programs issued provisos will receive their certificate following review and approval.
Standards for Accreditation
The Standards do not define who can interpret sleep studies. It is at the Independent Sleep Practice’s discretion to decide who may interpret; however, only licensed physicians, and Advanced Practice Providers 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-2 requires diagnoses made by individuals not board-certified in sleep medicine be reviewed by an individual who is board certified in sleep medicine.
When a non-board-certified physician’s diagnosis is reviewed, is signature by the individual board certified in sleep medicine required?
Yes, it must be indicated on the report that the diagnosis has been reviewed by the individual board certified in sleep medicine.
The AASM defines a direct referral as a patient that is tested by the Independent Sleep Practice but is not seen by facility professional staff prior to or after the test for follow-up. For example, if a patient is referred to your practice for testing and returns to their primary physician (not associated with your Independent Sleep Practice) for follow-up and treatment, the patient would be considered a direct referral.
One of the sleep program’s technologists was hired within the past year. Is the technologist required to have 30 sleep-related CECs?
Per the AASM Standards for Accreditation, all technical staff are required to earn 30 credits (averaged 10 credits per year over the past 36 months) of sleep-related continuing education credits; however, for a newly hired sleep technologist, the AASM may accept CECs prorated based on the hire date. For example, if a technologist has been working for the sleep program for one year, the AASM will require 10 sleep-related continuing education credits.
An advanced practice provider (NP, PA, APRN) was recently hired within the past year. Is the advanced practice provider required to have 30 credits in sleep medicine?
Per the AASM Standards for Accreditation, advanced practice provider (NP, PA, APRN) medical staff members are required to earn 30 continuing education credits (averaged 10 credits per year over the past 36 months) earned in sleep medicine; however, for a newly hired advanced practice provider (NP, PA, APRN), the AASM may accept continuing education credits prorated based on the hire date. For example, if an advanced practice provider (NP, PA, APRN) has been working for the sleep program for one year, the AASM will require 10 continuing education credits earned in sleep medicine.
Per Standard B-13, each Independent Sleep Practice shall comply with all background check requirements which may be required by federal, state, or local law. In the absence of such requirements, the practice shall conduct criminal background checks of all new employees. The practice shall utilize information obtained in this process only to the extent such information is relevant to the job duties of a particular person.
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 found under Standard F-3 – Subcontracting Scoring. Minimally, the subcontracting scoring company will need to be identified in the application.
Per Standard F-3, the facility is responsible for assessing the performance of the subcontractor in meeting contractual obligations including meeting applicable AASM Accreditation standards for scoring personnel. 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.
The practice must have a QA program for HSAT that addresses two process measures and one outcome measure. These measures may be chosen from the AASM Quality Measures.
The quality assurance Standard refers to a minimum threshold. Who defines the minimum threshold requirements?
The Standards do not define the minimum threshold (%). The quality assurance program, with oversight by the Principle Medical Staff Member, can assign minimum thresholds to their process or outcome measures that meets the practice’s goals.
Who should sign off on the quality assurance report? How long must I keep my quality assurance reports?
The Principle Medical Staff Member must review, report, and manage the quality assurance program on a quarterly basis as mandated in the Section J Standards. Quarterly, the Principle Medical Staff Member must attest to the effectiveness of quality improvement efforts and address plans for remediation of metrics that do not meet the minimal threshold. Quarterly reports must be signed and dated by the Principle Medical Staff Member and maintained for at least five years.
The Quality Assurance FACT Sheet provides general information on a quality assurance program. A sample quality assurance template report is available via Accreditation Reference Materials webpage.
Business Associate Agreement (BAA)
Why does the AASM require our entity to submit a HIPAA (Health Insurance Portability & Accountability Act) BAA?
The HIPAA Privacy Rule explicitly defines organizations that accredit covered entities as business associates. Like other business associates, accreditation organizations provide a service to the covered entity which may require sharing of protected health information.
The AASM offers a BAA that covers in-scope accreditation services. The AASM’s HIPAA BAA is available in the accreditation application or on the accreditation Reference Materials webpage. The AASM recommends the entity uses a pre-signed AASM BAA found in the accreditation application, which can be e-signed and submitted.
The AASM’s services are consistent for all entities; therefore, the AASM strongly recommends use of the AASM HIPAA BAA. In creation of AASM’s HIPAA BAA, the AASM had the BAA vetted by legal counsel specializing in HIPAA privacy. The AASM HIPAA BAA satisfies all requirements of business associates under HIPAA regulations.
Entities wanting to pursue a custom BAA may select “Custom BAA” in the accreditation application. A custom BAA must be uploaded in the accreditation application and a fee of $500 is payable at the time of the accreditation application submission. Customized agreements require careful review by the AASM and may require direct communication with the entity’s legal department. Entities pursuing a custom BAA need to allow an average of 4-6 weeks for review and potential revisions before the agreement is ready for signature.
The AASM does not create, maintain, or transmit any PHI of the covered entity. During the accreditation process, a site visitor will conduct an inspection of the entity to determine compliance with the Standards for Accreditation. During this inspection, our site visitor will review a set of patient records prepared by the entity. The site visitor will neither copy nor remove any PHI from the entity. Additionally, the AASM does not accept any PHI in response to additional information in support of the standards.
The BAA is a legal document only valid when signed by an authorized individual designated to review and approve official legal documents on behalf of an accrediting entity. Typically, hospital owned entities require a CEO’s or privacy officer’s signature. Freestanding entities may have the owner sign all legal documents. Entities applying for accreditation are responsible for determining the appropriate signatory ensuring that an authorized individual has reviewed and signed the agreement.