A Note on Accreditation

As we start off a new year, here are a few things to help make the survey process easier or maintain your accreditation.

The first thing I want to cover is the availability of your facility to use the document upload in the facility portal. If you are planning to share digital documents with the survey team this is the easiest way. You can also still use paper documents to provide to the survey team. These two ways are the best to ensure that the survey team has what they need during the survey.

Maintaining the currency of organizational information is important to your accreditation status. If there are any significant changes, please notify the UHMS within 30 days of the change. Failure to notify the UHMS may result in loss of accreditation. Depending on the nature and significance of the changes, an interim site survey may be required to maintain accreditation.

Below are representative examples of changes of which Society should be notified. It should be noted that these examples are not all-inclusive.

Site/Facility Change
Has your hyperbaric facility relocated since the completion of your last accreditation survey?
If so, please provide contact information for the new location.

Has your hyperbaric facility undergone remodeling or expansion since your last accreditation survey?
If so, please provide the details of the remodeling or expansion, such as the installation of additional chambers, new patient treatment rooms, etc.

Services Change
Has your hyperbaric facility added or deleted any services since completing your last accreditation survey?
If so, please provide details of the service change. Representative examples include, but are not limited to:

• Adding a comprehensive wound care service to your existing hyperbaric service
• Expanding your hyperbaric treatment coverage to a 24/7 full-service hyperbaric facility
• Reducing your hyperbaric treatment coverage from a 24/7 full-service hyperbaric facility to a non-24/7 service
• Cessation of treatment operations for an extended period

Merger/Joint Venture
Has your hyperbaric facility merged with another organization?
If so, please provide details of the merger and describe how the merger affects the management and operation of your hyperbaric facility (Policies and procedures and bylaws, Credentialing).

Has your hyperbaric facility entered into a joint venture with another organization?
If so, please provide details of the joint venture and how the joint venture affects the management and operation of your hyperbaric facility (policies and procedures and bylaws, credentialing).

Joint Commission (JC)/DNV-GL Change
The UHMS has a Complementary Cooperative Accreditation Agreement with the JC. We are required to track and list JC Accreditation on our Accredited Facilities List. If your status has changed we need to be notified within 30 days of the change. Example: If the organization changes from the JC to DNV-GL or DNV-GL to JC, please email the status change to us.

Service Provider (Contractor) Change
Has the hyperbaric service provider (contractor) of your hyperbaric facility changed in any way?
If so, please provide details of the new hyperbaric service provider (contractor). Also, describe how the management and operation of your hyperbaric facility differs with the new hyperbaric service provider (contractor) or internal management.

Key Personnel Change
Has the Medical Director of your hyperbaric facility changed?
If so, please provide information on the new Medical Director. A current curriculum vitae should also be provided.

Has the Clinical or Non-clinical Program Manager of your hyperbaric facility changed?
If so, please provide information on the new Program Manager. A current curriculum vitae should also be provided.

Has the Technical Director (if assigned) of your hyperbaric facility changed?
If so, please provide information on the new Technical Director. A current curriculum vitae should also be provided.

Has the Safety Director of your hyperbaric facility changed?
If so, please provide information on the new Safety Director. A current curriculum vitae should also be provided.

Has the Hyperbaric Survey Contact Person changed?
If so please provide their contact information. Please submit your change information, along with supporting documentation as required, within 30 days electronically to:

Derall Garrett, CHT
Hyperbaric Facility Accreditation Director
877-533-8467 ext 106 or 210-404-1533
derall@uhms.org

Beth Hands
Hyperbaric Facility Accreditation Coordinator
877-533-8467 ext 105 or 210-404-1553
beth@uhms.org