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Reframing a “Dependent Status” Survey Decision

By: Shannon Roberts, RN
Clinical Compliance Educator

Posted: June 16, 2025

Your behavioral health organization applied for ACHC Accreditation, hosted an onsite survey, and has now received a decision letter indicating “Dependent Status.”  What does it mean? And what happens next?

Dependent Status results when a substantial number of deficiencies is noted during a survey, or when the individual deficiencies are severe. Do not panic; this is not an uncommon result! Instead, reframe your perspective to view Dependent Status as a valuable second chance to validate compliance and your organization’s readiness to demonstrate safe, effective, high-quality care and services.

This decision status does indicate that an additional onsite survey is required to review areas of noncompliance. The resurvey is your opportunity to correct identified issues and implement sustainable improvements.

Eligibility requirements for resurvey

When survey findings result in a Dependent Status decision, your account advisor will send the decision letter with a detailed summary of findings, and a plan of correction (POC) template. Your organization must acknowledge areas of noncompliance and develop a functional and robust POC. ACHC requirements include mechanisms for evaluating and monitoring corrective actions for continued quality improvement and regulatory compliance. To be eligible for resurvey, your organization must complete the POC in its entirety and return it to ACHC within 30 calendar days (from the date of the Dependent Status letter). It will be reviewed for approval by the Accreditation Review Committee. If modifications to the POC are needed, you must revise and resubmit the POC within 10 calendar days.

After POC approval, your organization has 90 days (from the date of the Dependent Status letter) to provide ACHC with written notification of your readiness for resurvey (aka a Dependent Survey). Failure to meet this time frame will result in a final decision denying accreditation.

What to expect from a Dependent Survey

During the resurvey, your ACHC Surveyor will examine the POC and focus on the actions taken to correct the deficiencies. The purpose is to ensure that the behavioral health organization has:

  • Executed its corrective action plans and has taken approved steps to bring the deficiency into compliance.
    • HINT: The surveyor will review the specific action steps listed on your POC. The corrections could include revised policies and procedures, documented audit results, staff training logs, the development of a form such as a discharge summary, etc.
  • Identified the date of compliance for each action step.
    • HINT: All corrective action steps should be completed or in process on or before the POC is submitted to ACHC. Your surveyor will verify the documented date each action step was completed or in process of being corrected. The date of compliance must be within 30 calendar days.
  • Identified the title of individual responsible for ensuring each action step is completed.
    • HINT: The surveyor will expect to see the title of the individual responsible, not the individual’s name. Roles change and people leave positions, so assigning responsibility by title can help avoid revisions.
  • Established a monitoring process to prevent recurrence of non-compliance.
    • HINT: The surveyor expects to see documentation of a 2-step process to prevent recurrence of the deficiencies.
    • Step 1: Identify the percentage and frequency of records being audited and establish a target threshold or goal for compliance. The target is your benchmark for what is acceptable. For example, you may commit to auditing 10% of client records monthly until at least 95% of all records are in compliance.
    • Step 2: Address a plan to maintain compliance once the target threshold is met. Most organizations don’t want to continue high-volume, frequent chart audits when an issue has been resolved. A maintenance plan could be to audit the same percentage on a less frequent basis, or a lower percentage on the same cadence.

A survey for ACHC Behavioral Health Accreditation is a comprehensive review of your organization’s performance across various domains, including provision of care/services, safety, risk management, and overall compliance with state and federal regulations and accreditation standards. In essence, Dependent Status and a Dependent Survey serve to protect the organization’s interests, promote risk management, and ensure smooth and ethical operations and high-quality services.

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Read more articles about Behavioral Health Accreditation here.