Hospital Findings Reveal Persistent Compliance Challenges

By:Deanna Scatena, RN, BSN, Program Director

Deanna Scatena RN, BSN has extensive patient care experience that encompasses post-anesthesia care unit (PACU), critical care, and cardiac and thoracic nursing. Since joining ACHC, she has led the hospital programs by facilitating growth, broadening program offerings, and increasing educational support. Deanna also shares her knowledge as an educator, working with the ACHC team at trade shows and serving as a presenter for webinars and workshops.

Posted: December 19, 2025

Each year, the Quality Review edition of Surveyor identifies and analyzes the most challenging standards for ACHC-accredited hospitals. Overall, this year’s top survey deficiencies highlight a need for bridging gaps between policies and practices, ensuring all required standard elements are addressed, and fostering broader staff engagement across departments.

Acute care hospitals

Frequently cited Acute Care Hospital Accreditation Standards are generally consistent from year to year. Data from the latest Quality Review edition of Surveyor support this trend. Deficiencies are most common when the standard has a large number of required elements, affects multiple areas, or is tied to specific timelines.

This year’s most-cited standard—07.02.01 Risk Mitigation Measures for Infection Prevention—is the same as last year’s, underscoring an ongoing challenge for many hospitals. To improve, hospitals must focus on education and seek commitment from each individual in every department to find, report, and correct issues related to cleanliness and maintenance of the facility.

Critical access hospitals

As with acute care hospitals, the most challenging CAH Accreditation Standards tend to recur, affect the entire facility, and require numerous elements.

This year, two frequently cited standards were common to acute care hospitals and CAHs. Standard 18.02.01 Risk Mitigation Measures for Infection Prevention (07.02.01 for acute care hospitals) was the top deficiency once again. Expansive in scope, this standard encompasses all areas of the CAH and is assessed through direct observation.

Standard 06.03.08 Policy Requirements: Food Preparation and Storage (24.01.03 for acute care hospitals) is another consistent challenge. Survey findings often show a gap between policies and implementation practices.

Physical environment and life safety

Physical environment and life safety standards tend to produce a large number of deficiencies. This is not surprising, given that the physical environment is considered the hospital’s largest and most complex piece of medical equipment.

This year, seven frequently cited standards were common across surveys for hospitals of all sizes. Findings show that paying extra attention to even the smallest details can significantly reduce deficiencies.

New this year

Continuous improvement is woven into all we do at ACHC, including the annual Quality Review edition of Surveyor. In our recent issue, “tips for compliance” under each standard profile are enhanced to address varying levels of accreditation knowledge and experience across your agency. Explore our new Accreditation Nerd categories to see which is best for you. 

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