Revised: 07/24/2018 Page 1 of 1 I achc.org
[383] Accreditation Preliminary Evidence Report (PER) Initial Checklist
PRELIMINARY EVIDENCE REPORT (PER)
INITIAL CHECKLIST
This checklist constitutes the requirements of the PER, which is mandatory for organizations applying for initial Private
Duty accreditation.
Review and acknowledge that all of the following requirements have been met and submit this signed checklist with the
required items listed below.
Verification of the following is required for organizations seeking initial accreditation:
The organization must have provided care to a minimum of 5 clients/patients, having 3 active at time of survey unless
state law requires more
Confirmation of the following (initial in spaces provided):
___________ I attest that this organization possesses all policies and procedures as required by ACHC Accreditation Standards
___________ I acknowledge that this organization was/is/will be in compliance with ACHC Accreditation Standards as of
________________________________________ (date).
Your organization will be placed into scheduling once this document, the Agreement for Accreditation Services and Business
Associate Agreement are submitted to your Account Advisor and payments are up-to-date. ACHC will strive to
conduct your survey as soon as possible.
**PLEASE NOTE: YOUR ORGANIZATION MUST ALWAYS BE I N COMPLIANCE WITH APPROPRIATE STATE
REGULATIONS.
I, having the authority to represent this organization, verify that ______________________________________________________________ (organization’s
legal name) has met the above requirements for survey. Failure to meet any of the aforementioned requirements when the
ACHC Surveyor arrives on site may result in additional charges to the organization for a subsequent survey to be performed
when the organization has notified ACHC it has met all of the above requirements.
_____________________________________________________________________________ _____________________________________________________________________________
(Name) (Title)
_____________________________________________________________________________ _____________________________________________________________________________
(Date) (Signature)
click to sign
signature
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