Why Last-Minute Compliance Efforts Fall Short

By Lisa S. Meadows, MSW, Senior Manager, Survey Operations 

Lisa Meadows brings more than 30 years of experience to her role, providing in-depth clinical, accreditation, and industry education to ACHC customers and stakeholders. She supports interpretation of ACHC Standards and Medicare Conditions of Participation, helping organizations achieve and maintain excellence in patient care and regulatory compliance. 

Posted: June 9, 2026

Medicare certification and ACHC Accreditation for home health agencies both operate on a three-year schedule. While continuous compliance is expected throughout that period, some agencies adopt a temporary ramp-up mentality to ensure compliance just before their accreditation survey.

These agencies generally view survey readiness as a short-term compliance activity because accreditation looks at the organization at a particular moment in time. But the three-year cycle does not imply that compliance efforts should occur only when a survey approaches. For an agency demonstrating its commitment to high-quality patient care, continuous compliance should be as important as continuity of care.

Where compliance begins

To participate in Medicare, home health providers must meet the CMS Conditions of Participation (CoPs) outlined in 42 CFR Part 484. These regulations establish the minimum federal requirements for patient health and safety. In addition, providers must meet state requirements and ACHC Home Health Accreditation Standards, which align with CMS CoPs. Together, these regulations address critical areas that include but are not limited to:

  • Administrative and organizational operations.
  • Patient rights.
  • Initial and comprehensive assessments.
  • Interdisciplinary care planning.
  • Quality assessment and performance improvement (QAPI).
  • Infection prevention and control.
  • Emergency preparedness.
  • Clinical documentation.

Consistent, continuous compliance matters. Organizations accredited by ACHC are expected to maintain ongoing compliance, not simply during renewal periods. Failure to maintain steady compliance can result in deficiencies, corrective action plans, civil monetary penalties levied by the state, or even termination from Medicare participation.

Reactive vs. proactive compliance

The attempt to achieve compliance right before a survey is a risky approach. Agencies that focus on standards only in the months leading to a survey often struggle with incomplete documentation, gaps in staff knowledge, and unresolved operational deficiencies.

Fixing errors found during a last-minute internal audit may address problems as single issues, but it can hide a trend that would have been visible if audits had been conducted consistently and strategically. Embedding readiness into daily operations, culture, and leadership expectations is a more practical strategy.

Agencies that proactively review charts and focus on high-risk areas like eligibility documentation, plans of care, and medication profiles are better positioned for success. These organizations show greater operational stability and stronger survey outcomes. Demonstrating the ability to self-identify areas for improvement, and establishing and implementing a plan of correction, reinforces a provider’s commitment to compliance and quality patient care.

Take it from the top

For home health providers, ongoing survey readiness begins with leadership commitment. Administrators and clinical managers should audit organizational requirements and conduct regular mock surveys, policy reviews, medical chart audits, infection control monitoring, personnel file reviews, and home visits.

Continuous staff education is equally important to ensure employees understand regulatory expectations and can demonstrate competency during survey interviews.

Agencies that integrate continuous compliance into routine workflows are more likely to identify deficiencies early and implement corrective actions before issues escalate.

Supporting excellence

Maintaining survey readiness protects organizations operationally and financially while supporting safe, patient-centered care. Ultimately, continuous compliance fosters a culture of accountability, quality improvement, and organizational excellence.

Agencies that remain survey ready every day are better positioned to succeed during accreditation surveys, maintain Medicare certification, and deliver consistent, high-quality care to the patients and families they serve.

Simply put, there is no such thing as “episodic compliance.” ACHC Accreditation requires continuous compliance with the standards and all applicable state requirements.

Checklist available

ACHC has created resources to help. Click here to access an Accreditation Annual Compliance Checklist. Use this checklist to audit your agency for compliance with annual requirements.

Note: This checklist is current as of the publication date. Log in to your customer portal to access the most updated version.

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