Survey Readiness Starts With Medical Records

By Becky Tolson, RN, BS, Manager, Survey Operations

Early in Becky Tolson’s nursing career, she provided infusion services to home health patients. The expertise she developed led to consulting roles with home health agencies planning to offer home infusion services. At ACHC, she supports surveyors across all home care programs. In demand as an educator at industry conferences, Becky also leads ACHCU webinars for providers seeking accreditation guidance.

Posted: February 2, 2026

When an ACHC Surveyor arrives at your agency, access to medical records should be among your first expectations for the survey process. Record review is a critical source of evidence used to evaluate compliance with federal and state regulations, ACHC Standards, and organizational policies.

Surveyors must be granted prompt access to requested records to effectively assess the quality, safety, and continuity of patient care. In addition, timely access to documentation—or the lack thereof—leaves a lasting impression on your surveyor. Delays impede the surveyor’s ability to validate compliance and may indicate ineffective medical record management practices.

Surveyors may request current or closed records to review compliance trends, validate corrective actions, or investigate complaints. When records cannot be produced promptly, or when documentation is incomplete, it raises concerns about record organization, retention practices, or system reliability. Even when care was appropriately provided, lack of timely access may result in deficiencies due to the organization’s inability to demonstrate compliance.

Record retention

Maintaining complete, accurate, and accessible medical records for the required retention period is a foundational responsibility for Medicare-certified home health providers. Under the Medicare Conditions of Participation (CoPs) at 42 CFR §484.110, home health providers are required to maintain clinical records for a minimum of five 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.

Medical record retention is not merely an administrative function. It is a critical compliance and risk management responsibility that directly impacts survey outcomes, payment integrity, and an organization’s ability to demonstrate sustained compliance.

Following a change in ownership, responsibility for medical record retention and accessibility transfers to the new owner. Under 42 CFR §484.110 and ACHC Standards, medical records created prior to the ownership change remain part of the legal medical record and must be retained for the full five-year retention period, or a longer period if required by state law. The organization must ensure these records are readily retrievable and available to ACHC Surveyors upon request, regardless of storage method, location, or prior vendor arrangements. Failure to maintain access to records from a prior owner may result in survey deficiencies and may indicate a breakdown in governance and compliance oversight.

Legacy systems

Similarly, when an organization transitions to a new electronic medical record (EMR) system, it remains fully responsible for maintaining access to all records created in the previous system. Closed records must remain secure, intact, and retrievable throughout the required retention period. Records maintained in legacy systems must be accessible without delay during a survey. Inability to retrieve records from a prior EMR system may result in deficiencies and may demonstrate noncompliance with requirements for medical record management.

Finally, medical record retention and accessibility are vital to an agency’s risk management process. Medical records may be required years after services are provided to respond to complaints, audits, medical review activity, or legal actions. Compliance with the home health CoPs and ACHC Standards supports the organization’s ability to demonstrate that care was provided according to accepted standards and regulatory requirements. Missing, incomplete, or inaccessible records increase regulatory risk and potential liability.

By prioritizing timely access, effective retention practices, and strong record governance, organizations demonstrate survey readiness and regulatory compliance—good indicators of a commitment to high-quality, patient-centered home health care.

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Read more articles about Home Health Accreditation here.