Medical Record Management Supports Quality Hospice Care
By: Lisa Meadows, MSW, Senior Manager, Survey Operations
Lisa Meadows brings more than 30 years’ 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: February 2, 2026
Medical record management is a common concern as hospice agencies balance regulatory requirements, accreditation compliance, risk management, and quality patient care.
From a regulatory perspective, maintaining complete, accurate, and accessible medical records throughout the required retention period is a foundational responsibility for Medicare-certified hospice providers. Under the Medicare Conditions of Participation (CoPs) at 42 CFR §418.104, hospice providers must keep clinical records for a minimum of six years following the date of discharge. ACHC Standards align with and reinforce this requirement, emphasizing that records must be maintained to ensure availability, integrity, and confidentiality throughout the retention period.
When there is a change in agency ownership, responsibility for medical record retention and accessibility transfers to the new owner. Records created prior to the ownership change remain part of the legal medical record and must be kept for the full six-year retention period, or any longer period required by state law. The organization must further ensure these records are readily retrievable and available to ACHC Surveyors upon request, regardless of storage method, location, or prior vendor arrangements. Failure to support access to records from a prior owner may reflect a breakdown in governance and compliance oversight that results in survey deficiencies.
Similarly, when an organization transitions to a new medical record system— a new EMR, for example—the responsibility to maintain access to all records created in the previous system remains. ACHC Standards and the Medicare CoPs require that closed records are still secure, intact, and retrievable throughout the required retention period. Records maintained in legacy systems must be accessible without delay during a survey. The inability to retrieve records from a prior system may result in deficiencies related to medical record management.
Compliance requires timely access
When an ACHC Surveyor arrives onsite, timely access to documentation is a critical part of the accreditation survey process and a core expectation. Medical records are a primary source of evidence used by surveyors to evaluate compliance with federal and state regulations, ACHC Standards, and organizational policies. Surveyors may request current or closed records to review compliance trends, validate corrective actions, or investigate complaints. When records cannot be easily produced, it raises concerns about record organization, retention practices, and system reliability.
Prompt access to requested records promotes effective, efficient assessment of the quality, safety, and continuity of patient care. Even when care was appropriately provided, delayed access to records may result in deficiencies due to the organization’s inability to show compliance. Delays, incomplete documentation, or inability to retrieve records upon request may result in survey deficiencies.
Risk management concerns
Medical records may be sought years after services are provided to respond to complaints, audits, medical review activity, or legal actions. Demonstrated compliance with the hospice CoPs and ACHC Standards support the organization’s ability to prove that accepted standards and regulatory requirements governed the delivery of care. Missing, incomplete, or inaccessible records increase regulatory risk and potential liability.
In summary, record retention is not merely an administrative function. It is a critical compliance and risk management responsibility that directly affects survey outcomes, payment integrity, proof of sustained compliance, and commitment to high-quality, patient-centered hospice care.
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