Plan for Reaccreditation with a Look Back
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: August 3, 2026
After your agency’s initial Home Health survey, you focused on the required plans of correction and your agency was awarded ACHC Accreditation. Congratulations! Now it’s time to ensure success at your renewal survey.
One of the most important concepts to remember is the compliance or readiness date you identified during the application process. When selecting your compliance date, you attested that your home health agency would meet all applicable ACHC Accreditation Standards, which include the Medicare Conditions of Participation (CoPs) as well as requirements that go above and beyond the CoPs, beginning on that date and continuing thereafter.
Meeting requirements
There may have been activities completed before the readiness date that did not fully meet ACHC requirements. For example, staff hired prior to that date may not have received orientation training on all required topics. They may not have completed annual training required by ACHC or have documentation of demonstrated competencies.
Your compliance date also applied to review of patient care activities. Patients admitted prior to the compliance date may not have had documentation that fully reflects current ACHC Standards.
During your initial survey, the surveyor may have identified these gaps and provided education about the expectation for future compliance, but these standards were not cited as deficiencies because they occurred before your established compliance date.
However, all admissions, assessments, interdisciplinary plans of care, patient rights, informed consent, medication management, and discharge documentation completed on or after your readiness date are expected to meet ACHC requirements.
Continuous compliance
As you prepare for your reaccreditation survey, remember that accreditation is not a one-time event—it is an ongoing commitment to quality.
All Medicare CoPs were evaluated at the time of your initial survey. At the time of renewal, any of your agency's operational processes—emergency preparedness, infection prevention activities, adverse event tracking, and quality assessment and performance improvement (QAPI) initiatives—that required a plan of correction after your initial survey must demonstrate continuing compliance.
In addition, ACHC Surveyors will expect to see that staff receive required orientation and annual education and that all other ACHC Standards have been consistently implemented since your compliance date.
The goal is not simply to check the boxes for accreditation but to build a culture of continuous compliance and excellence that exceeds both ACHC Accreditation Standards and the federal and state requirements governing home health care.
Your accreditation partner
ACHC is committed to acting as a partner throughout your accreditation cycle. ACHC Home Health Accreditation Standards are your primary source for current requirements and evidence that surveyors use to assess your agency.
In addition, ACHC offers a variety of resources and tools to help your organization remain survey ready, including an Accreditation Annual Compliance Checklist specific to home health. This is a concise summary of ACHC requirements to help you routinely assess your compliance. (Please note, this checklist is current as of the publication date. Log in to your customer portal to access the most updated version.)
Again, congratulations on your commitment to excellence through ACHC Home Health Accreditation. We look forward to an ongoing relationship as you continue to provide exceptional, compassionate care to the patients and families you serve.
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