What is Accreditation?
Why Achieve Accreditation?
Why ACHC Accreditation?
Transition to ACHC
Frequently Asked Questions
The organization must have provided care to a minimum of 10 patients requiring skilled care (not required to be Medicare beneficiaries). At least 7 of the required 10 patients should be receiving skilled care from the home health agency at the time of the Medicare survey, unless in a medically underserved 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.
ACHC currently provides licensure surveys on behalf of California, Florida, Missouri, New Mexico and Texas. The process for Texas licensure surveys is the same as our Medicare certification process, but we have a two-step process for California, Florida, Missouri, and New Mexico licensure surveys. The following tools provide more information about ACHC’s two-step process in these states:
The ACHC compliance date is the date on which you acknowledge that your organization was/is/will be in compliance with the ACHC Accreditation Standards. The compliance date does not apply to state and Medicare CoPs, as agencies must always be in compliance with these requirements from the initiation of patient care.
There are no capitalization requirements for a hospice. A hospice may have its own capitalization budget for future growth, adding an inpatient, etc., but it is the hospice governing board’s decision on when to use it. However, some states may have a capitalization requirement through their licensure or CON.
The organization must have provided care to a minimum of 5 patients (not required to be Medicare beneficiaries). At least 3 of the required 5 patients must be receiving care at the time of the Initial Medicare Certification Survey, unless in a medically underserved area as determined by the Regional Office.
Yes. All hospice providers, regardless of the ability to bill, must be able to provide all four levels of care: routine, respite, continuous, and short-term inpatient.
ACHC currently provides licensure surveys on behalf of Texas, Missouri, and New Mexico. The process for Texas licensure surveys is the same as our Medicare certification process, but we have a two-step process for Missouri licensure surveys. The following tools provide more information about ACHC’s two-step process in these states:
The ACHC compliance date is the date at which you acknowledge that your organization was/is/will be in compliance with the ACHC Accreditation Standards. The compliance date does not apply to state and Medicare CoPs, as agencies must always be in compliance with these requirements from the initiation of patient care.
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.
Agencies can provide 5 mock files at the time of survey if equipment or supplies have not been provided. A mock file is a sample patient file that should be set up to include all required information/content that would be present in a true patient file.
You should apply to CMS for your DMEPOS Medicare number after you have been approved for accreditation.
There is no specific requirement; however, enough information about compounding must be demonstrated for the Surveyor to assess compliance with PCAB standards. This includes record keeping, ingredient selection, and personnel training and competency. If you are not currently compounding, please schedule time to speak with your Account Advisor about your unique situation.
The total number of patients admitted one time over the past 12 months, regardless of the type of services, frequency of admission, or payor source. If a patient was admitted, discharged, and later in the year readmitted, that patient should NOT be counted twice. If a patient is evaluated, but not admitted, that patient should not be counted.
The time frame to complete the accreditation process is dependent upon how soon your organization submits all required information. This includes the signed Accreditation Agreements and signed PER Checklist. Generally speaking, your organization can expect an on-site survey within 45-70 days from the submission date of all required information.
Most surveys are unannounced. However, there are some instances in which we conduct announced surveys. Announced versus unannounced surveys depend upon the program and services for which you are seeking accreditation. Your personal Account Advisor will be able to provide you with more specific information.
Notification call – 1-2 hours in advance of the on-site survey, the Surveyor will call the contact provided on your application to notify your organization of the survey.
Opening conference – The Surveyor will hold a short opening conference to set expectations for the survey.
Tour of facility – The Surveyor will ask for a brief tour of the facility.
Personnel record review – The Surveyor will review a random sampling of personnel records including key administrative and clinical staff.
Patient chart review – The Surveyor will review a representative sample of patient charts.
Patient home visits/calls – Depending on the program being surveyed, the Surveyor will either call patients or conduct home visits to observe services and care being provided
Interviews – The Surveyor will conduct interviews with staff, management, governing body, contracted personnel, and volunteers throughout the on-site survey.
Policy & Procedure Review – The Surveyor will review the agency’s implementation of policies and procedures, including Performance Improvement (PI).
Exit conference – For surveys lasting more than one day, the Surveyor will hold a mini exit conference at the end of each day to review progress of the survey and outstanding items to be reviewed. At the end of the survey the Surveyor will hold a final exit conference to discuss the findings and offer guidance on how to correct the deficiencies. Surveyors will not be making an accreditation decision on site.
All ACHC Surveyors have extensive experience in the field they survey and have completed on-site orientation and a preceptorship as well as ongoing training. All Home Health, Hospice, and PD Surveyors are Registered Nurses; all Pharmacy Surveyors are Pharmacists with management experience; and all DME Surveyors have HME management, compliance, or accreditation experience.
To help ensure that your organization experiences no lapse in accreditation, we recommend that you submit your renewal application 6 months prior to your expiration date. This allows time for your agency to prepare for the on-site survey.
Accreditation University (AU) offers a variety of exceptional educational resources to help your organization prepare for and maintain accreditation. If you are new to accreditation, coming up on renewal, or just want to learn more, our program-specific accreditation workshops are a great place to start.
We do not charge any annual fees to remain accredited.
No, we do not charge for any Surveyor expenses.
1) Balance is due in full within 30 days of execution of signed contract
2) Balance is broken down into 3 equal payments due 30/60/90 days (3 months) after execution of signed contract
3) Balance is broken down into 6 equal payments due 30/60/90/120/150/180 days (6 months) after execution of signed contract
*NOTE – If you choose option 2 or 3, there will be a one-time 10% surcharge added to the balance. Both options can also be set up to auto draft.