ACHC FAQs

ACHC Accreditation is independent third-party validation, through a comprehensive survey process, that a healthcare organization’s policies, processes, and care delivery meet recognized standards for quality and safety.

ACHC Certification is a focused review and evaluation of a defined program within a healthcare organization as measured against recognized standards for specialty care.

Each provider or supplier organization delivers care/supports the needs of a defined patient population. For some ACHC programs, standards are categorized under Services to ensure relevance to the care provided by organizations seeking accreditation.

Log into your customer portal (details below) to access, complete, and submit your accreditation or certification application. If you have questions or need assistance, call (855) 937-2242 or email customerservice@achc.org.

Customer Central for the following programs: Ambulatory Care, Assisted Living, Behavioral Health, Dentistry, DMEPOS, Home Care, Home Health, Home Infusion Therapy, Hospice, Palliative Care, Pharmacy, PCAB, Renal Dialysis, and Sleep Accreditation and Telehealth Certification.

Compass for the following programs: Acute Care Hospital, Ambulatory Surgery Center, Clinical Laboratory, Critical Access Hospital, and Office-Based Surgery Accreditation and Joint Replacement, Lithotripsy, Stroke, and Wound Care Certification.

Generally, your organization can expect a survey less than 90 days from the submission date of all required information. For new organizations seeking initial accreditation, an accelerated option may be available. Call (855) 937-2242 or email customerservice@achc.org for information about ACHC’s TIME program.

To help ensure that your organization experiences no lapse in accreditation, we recommend that you submit your renewal application six months before your expiration date. This gives your organization time to prepare for your survey and also allows time for ACHC’s scheduling team to identify a great Surveyor/survey team in a reasonable time frame.

The Preliminary Evidence Checklist (PER) lists items that must be completed and submitted before the accreditation process continues. The form is required only for community-based case organizations seeking initial accreditation and does not apply to ACHC acute care accreditation programs.

Items required vary based on the accreditation program and services requested by an applicant organization. A representative of your organization must sign the form, to attest that your organization meets all requirements and is ready to be surveyed. The PER is available to download from your customer portal.

If your organization wants to become or remain a Medicare-approved provider or supplier, your “deemed status” survey will be unannounced. Other surveys, including on-site accreditation or certification surveys and virtual surveys (where available), are scheduled in collaboration with the applicant organization.

For more information, contact your Account Advisor.

On-Site Surveys

Deemed status accreditation surveys: No. The Centers for Medicare & Medicaid Services (CMS) no longer allows accreditation organizations to alert healthcare organizations before an unannounced survey for deemed status  accreditation.

ACHC previously notified community-based clinical programs 30 minutes prior to arrival for a deemed status survey.

In accordance with new CMS rules, your ACHC Surveyor will arrive without prior contact within your posted hours of operation to conduct a survey.

The CMS change is intended to ensure that organizations seeking Medicare initial certification or recertification are open and operational during established working hours.

Non-deemed accreditation surveys: Yes, for most organizations. Community-based organizations will continue to be contacted before a survey for non-deemed accreditation — unless your state requires an unannounced survey or your non-deemed survey is conducted at the same time as a deemed accreditation survey for another service.

Your Account Advisor can provide additional information. If applicable, ACHC will notify organizations on the morning of the survey, before the Surveyor arrives. As a safety protocol, we will notify the contact person specified on your application.

Virtual Surveys

The ACHC virtual survey coordinator will contact your organization via email 48 business hours before your survey.

Your ACHC survey is an independent assessment of your organization’s compliance with recognized national standards for quality and safety conducted with an educational approach designed to maximize your organization’s capacity for excellence.

The survey begins with an opening conference at which introductions are made, the survey agenda is finalized, and expectations are established.

Your Surveyor/survey team will assess compliance in three ways:

1. Through direct observation of care and services being provided.
2. Through interviews of select personnel, employees, and contracted individuals who provide care on behalf of your organization. Also, if applicable, through patient interviews.
3. Through review of documentation that supports compliance with ACHC Standards and applicable federal and state regulations. The same materials will be reviewed during an on-site or virtual survey.

The survey ends with a closing conference. Your Surveyor/survey team will review the preliminary summary of findings. Surveyors do not make the accreditation determination. After your survey, the survey results will be submitted to the relevant ACHC office-based team for review and processing.

As your partner, ACHC is always here to help. After applying for accreditation or certification, your personal Account Advisor is dedicated to answering questions and meeting your needs. Clinical experts are also available to assist you. Program-specific information can be found on the Customer Central portal or through your program team.

In addition, a comprehensive library of educational tools and resources to help you prepare for and maintain accreditation is offered by ACHCU, the education division of ACHC. Information on program-specific accreditation tools, workshops, webinars, and other educational materials can be found at achcu.com.

Yes, the surveyor observes personnel performing services in the field. ACHC must verify that services are being provided per our standards and your policies and procedures.

The number of files reviewed depends on the size of the organization, but a minimum of three files must be reviewed during the survey.

The surveyor will review the files of dentists, dental hygienists, and dental assistants involved in the provision of services. They may also review the file(s) of office managers and billing staff.

Being recognized as an accredited organization offers significant competitive advantages. Facilities that contract with mobile dentistry providers often require accreditation, because achieving accreditation provides assurance that your practice delivers the highest quality of care. Accreditation also optimizes and strengthens your practice by driving performance improvement, refining operating efficiencies, and managing risk – key aspects of a successful business strategy.

A minimum of five (5) client/patient records will be reviewed. Records should cover all applicable ACHC DMEPOS services for which the organization is seeking accreditation (HME, Fitter, MSP, RTS, CRTL, CRDS). If there are more than five (5) clients/patients, the surveyor will randomly select which client/patient records to review. All records must show compliance with the DMEPOS Quality and Supplier Standards.

• If your organization does not have a PTAN, client/patient records can be from multiple payor sources such as Medicaid, third-party payors, or cash transactions.
• If your organization has a PTAN, Medicare-compliant client/patient records are required for survey.
  • Provide a list/report of Medicare Part B DMEPOS clients/patients so the surveyor may randomly select records to be reviewed.
  • Prior to survey, verify with the appropriate person/department at your organization whether claims have been submitted to Medicare.
  • If no Medicare Part B DMEPOS claims have been submitted, the surveyor will document the reason why, and ACHC can request an exception for your organization.
  • CMS will fact-check the information. If claims have been submitted to Medicare, ACHC will schedule time at a later date to review client/patient records, prior to rendering your accreditation decision.

If you have questions about client/patient record review requirements, contact your account advisor prior to your survey.

A home health agency seeking Initial Medicare Certification must have an approved CMS-855A Medicare Enrollment Application – Institutional Providers Form from the Centers for Medicare & Medicaid Services (CMS) to begin the accreditation process.

The organization must have provided care to a minimum of ten (10) patients requiring skilled care (not required to be Medicare beneficiaries). At least seven (7) of the required ten (10) patients should be receiving skilled care from the home health agency at the time of the Medicare survey, unless the care is provided in a medically underserved or rural area as determined by the Regional Office.

You must be providing or have provided skilled nursing care and at least one other therapeutic service such as physical therapy, occupational therapy, speech therapy, home health aide services, and/or medical social services.

To determine if a CON is required for the state in which you want to operate a home health agency, visit the National Conference of State Legislatures CON-Certificate of Need State Laws page online.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Home-Infusion-Therapy/Overview.html.

ACHC must assess the care provided in the home as part of the survey process. Not having any active patients could result in negative survey results requiring another onsite survey.

Yes. Conducting interviews to validate findings from observations and record reviews is a standard part of survey procedures. Interviews involving personnel, patients, and family members or caregivers, must be conducted confidentially.

Interviews with patients, family or caregivers will be conducted in a confidential manner to allow any concerns related to patient care to be freely discussed with the surveyor.

Interviews with staff will be conducted in a confidential manner to allow any concerns to be freely discussed with the surveyor.

There must be an employee available in the office throughout the survey to provide the surveyor with required information. Key personnel must also be available throughout the survey for interviews.

In most situations, there will only be one ACHC surveyor. However, there may be additional individuals present, such as a preceptee ( a surveyor in-training), a manager for supervisor oversight, or a CMS surveyor for AO oversight.

The number of medical records and home visits will be determined by your unduplicated admissions for the past 12 months or since the start of business, if a new agency. The chart below details the number of patient medical records and home visits that are required per unduplicated admissions.

Hospice Sample Record Review and Home Visit Requirements

ACHC requires that the office-based surgery (OBS) practice serve at least three (3) patients before the survey. Additionally, ACHC requires that you have one (1) active procedure on the day(s) of the survey.

Yes, ACHC provides resources and tools to help office-based surgery (OBS) organizations prepare for accreditation surveys. This includes a free self-assessment tool that allows new applicants to conduct their own mock surveys and set themselves up for success. In addition to tools, an office-based surgery will have access to our Clinical Review Specialists team for information and guidance.

Yes! Every office-based surgery (OBS) practice is assigned a dedicated Account Advisor to help your team navigate the accreditation process. The Account Advisor will serve as your liaison with ACHC’s other internal resources such as our Physical Environment expert and our Clinical Review Specialists.

THIRD-PARTY RECOGNITION – PCAB Accreditation meets compliance requirements for a growing number of payors and networks.

IMPROVED QUALITY AND SAFETY – In achieving PCAB Accreditation, pharmacies benefit from consistent practices that result in improved safety, efficiency, and quality of care.

RISK AVERSION – Adherence to PCAB standards helps pharmacies maintain compliance with all applicable USP guidelines.

MARKET ADVANTAGE – PCAB Accreditation allows pharmacies to distinguish themselves among their competitors by demonstrating a commitment to compliance with USP guidelines as well as industry best practices.

OPERATIONAL EFFICIENCIES – PCAB’s educational approach to accreditation enhances business operations, helps inform effective strategies, and improves patient outcomes through evidence-based best practices.

CONTINUITY OF SERVICE – PCAB facilitates a standardized level of service that includes sound procedures, documentation, and training to ensure consistent performance across the entire organization.

To have our Surveyors best evaluate your compounding processes, we ask that you have completed 30 to 90 days of compounding. Recordkeeping, ingredient selection, clean room certification, and personnel training and competencies should also be completed. If you are not currently compounding, please discuss your situation with your Account Advisor.

PCAB remains the gold standard in compounding accreditation, providing pharmacies with a comprehensive peer review of practices and corrective measures to achieve compliance with USP guidelines. Achieving PCAB Accreditation confirms your commitment to meeting the highest industry standards for quality and safety.

Pharmacy Inspection Services (INSP) are state-approved inspections for pharmacies that perform compounding, regardless of accreditation status. Inspection criteria are customized for each state. These inspections verify that state board of pharmacy requirements and USP compounding standards are met.

IRX Accreditation is chosen by pharmacies that need a Medicare Part B billing number to receive reimbursement for infusion pumps and related supplies. Infusion Pharmacy services include IV drug mixture preparation, IV administration, therapy monitoring, client/patient counseling, and education. Accreditation confirms compliance with USP standards for sterile and non-sterile preparations.

PCAB Accreditation is appropriate for pharmacies in a variety of settings that want to demonstrate compliance with USP standards for sterile and/or non-sterile compounding.

PCAB Accreditation offers the most comprehensive compliance solution in the industry, with standards based on U.S. Pharmacopeia (USP) requirements. Achieving PCAB Accreditation demonstrates your commitment to meeting the highest industry standards for quality and safety.

PCAB reviews pharmacies that compound medications in retail, hospital, mail order, or closed-door settings.

Updates to USP compounding standards take effect November 1, 2023. Until that date, ACHC Surveyors are surveying to USP General Chapter <795> for non-sterile compounding, 2014 version, and USP General Chapter <797> for sterile compounding, 2008 version. Facilities implementing the 2023 updates before the November deadline will not be cited during their accreditation survey for following the revised standards.

ACHC is an accepted accreditor in all Medicare LCDs.

ACHC standards cover and expect compliance with Medicare regulations, which includes Medicare LCD coverage criteria. LCD content may differ from region to another, and you must comply with what your LCD requires.

ACHC standards follow CMS requirements for sleep staff credentialing. Ensure you are meeting the exact requirements of the LCD for your market by checking cms.gov and locating the LCD specific to your state. Sign up and download our guide to help determine your next steps.

No. ACHC standards require that the medical director be a physician (MD/DO) who has experience in sleep medicine. Board certification is required for the physician who interprets sleep studies.

That is your choice! ACHC offers multiple accreditation options for your organization.

• You can accredit your facility for in lab testing only, or
• You can accredit your facility for home sleep testing only, or
• You can accredit your facility for in lab testing AND home testing.

In most cases, a percentage of your locations will be surveyed. We’ll review your application and contact you with more information.

The accreditation period is three years. We find that a three-year cycle promotes patient safety and prevents fraud, waste, and abuse.

Sleep accreditation surveys are announced and scheduled in advance with the organization.

If your organization is applying for initial accreditation, you will be asked to submit a “readiness date” prior to being scheduled for survey. Choosing a realistic, attainable readiness date is essential to a successful survey. Your surveyor will hold your organization accountable for compliance with all ACHC Accreditation Standards as of this date

It depends. Eligibility for virtual surveys is determined by the selected services and your organization’s history with prior surveys. We’ll let you know if you qualify.

Patients are not required to be present during the survey; however, the surveyor will ask to speak to patients who have received sleep testing from the organization.

Your ACHC surveyor will speak with multiple staff members, and one person may hold multiple positions. Please have a representative available for these roles:

• Facility manager/owner/director (as applicable)
• Facility medical director (at a minimum, available for potential questions via phone) and/or interpreting physician
• Sleep technologist
• Office manager/billing representative/scheduling representative
• Facility compliance officer and PI coordinator
• Human resources (required to present documents for personnel, contract personnel, physician credentialing). See SLC 4–1C.
• Medical records (will be required to present patient files). See SLC 5–1A.
• Safety/infection control
• IT security
• If using contract services, include a representative who can access and/or provide any requested document not available onsite (e.g., policies/procedures, personnel files, contract for services/BAA/terms page, professional liability insurance, PI data, etc.)

Telehealth is the provision of care to patients with acute or chronic conditions using telehealth technology to allow monitoring in the home environment and other remote locations.

Use of telehealth technology creates disease management empowerment and independence, improved access to care, increased collaboration among healthcare providers, and improved patient outcomes.

Telehealth may include remote patient monitoring (RPM), biometrics, video, talk, or education. ACHC Standards for Telehealth Certification are based on the American Telemedicine Association’s Home Telehealth Clinical Guidelines.

Telehealth and telemedicine are two different types of online healthcare services. Telemedicine refers specifically to online doctor visits, while telehealth also includes health-related education services like diabetes management or nutrition courses and health-related training.

Certification is a vital tool to optimize and strengthen your organization. ACHC Certification is a focused review and evaluation of a defined program within a healthcare organization as measured against recognized standards for specialty care.

Certification, like accreditation, requires a survey — an independent, third-party review of your organization. ACHC uses an educational, collaborative survey approach that helps drive performance improvement, operating efficiencies, and risk management strategies.

By achieving certification, you demonstrate your commitment to high standards for quality, safety, and consistency.

Accreditation is independent third-party validation, through a comprehensive survey process, that a healthcare organization’s policies, processes, and care delivery meet recognized standards for quality and safety.

Certification is a focused review and evaluation of a defined program within a healthcare organization as measured against recognized standards for specialty care.

An ACHC award of Distinction is based on a focused review and evaluation of a defined specialty service offered by an ACHC-accredited healthcare organization as measured against recognized standards for specialty care.

All three categories focus on improving patient outcomes through effective processes that ensure the individual needs of patients are met with the highest-quality care and services. Each recognizes an organization’s commitment to continuous quality improvement, business efficiency, and safety.

Telehealth services have expanded dramatically during the COVID-19 pandemic and are expected to remain an important part of the healthcare continuum.

ACHC Telehealth Certification establishes national standards to promote best practices for delivering the highest-quality digital healthcare services. Certification confirms the quality of your services — strengthening trust in your organization and assuring patients they are receiving the best care.

As telehealth adoption increases, payors are likely to require third-party validation, like certification, to distinguish quality of care and validate service delivery. Our standards were developed with the future in mind, keeping you ready to meet possible payor requirements.

Telehealth Certification does not require accreditation from ACHC or another accreditor. It is available for any healthcare individual or organization that delivers health-related services via electronic information and telecommunication technologies.

The Distinction in Telehealth requires ACHC Accreditation. To apply for the Distinction in Telehealth, you must be accredited or seeking accreditation in one of seven ACHC programs: Ambulatory Care, Behavioral Health, Home Health, Hospice, Palliative Care, Private Duty, and Renal Dialysis.

If you are already accredited by ACHC in any of these programs or are seeking accreditation in any of them, it is recommended that you apply for the Distinction in Telehealth. Please contact your Account Advisor for more information.

If you are accredited by ACHC under a different program or are not accredited and do not want to be accredited, you should apply for ACHC Telehealth Certification.

Both Telehealth Certification and the Distinction in Telehealth focus on the provision of health care via telehealth technology to promote best practices for optimal care, privacy, cybersecurity, and safety.

Standards were developed in collaboration with leading industry associations and experts and are based on the American Telemedicine Association’s Home Telehealth Clinical Guidelines.

As a telehealth provider, delivering quality care and services is your highest priority. Achieving ACHC Telehealth Certification confirms your dedication to providing the best care and services.

Benefits include:

• Accountability
  Confirm your commitment to quality, patient privacy and safety, cybersecurity, and consistency.
• Credibility
  Elevate your organization’s standing and gain industry credibility.
• Minimized risk
  Maximize value while minimizing risk.
• Competitive advantage
  Stand out among competitors. Be ready for possible payor requirements.

Your goals are our goals. ACHC understands the trust placed in your organization for delivering reliable, first-rate care and services.

Like you, we focus on improving patient outcomes. With your needs in mind, we use a more collaborative, educational approach that helps you continuously enhance the quality of your services and improve operational efficiencies.

ACHC’s cost-effective, streamlined process is designed to help you quickly and easily achieve certification. Our dedicated staff is ready to assist you before, during, and after your survey. Educational resources also are available to support your team and further your success.

At ACHC, we are more than an accreditor. We focus on empowering you to meet your strategic goals — and build a lasting partnership along the way.

Organizations are welcome to contact ACHC and explore their options for recognition of telehealth services. ACHC staff is available to discuss the best solutions for your organization.

Call (855) 937-2242 or email customerservice@achc.org to learn more.