Tackling Hospice Accreditation Challenges

By: Susan Mills, RN, Senior Program Director

Susan Mills worked more than three decades as a registered nurse serving home health and hospice organizations. In her current role at ACHC, she guides Hospice, Home Health, and Home Infusion Therapy Accreditation. She also manages ACHC staff who oversee Assisted Living, Behavioral Health, Home Care, Palliative Care, and Renal Dialysis Accreditation.

Susan’s experience informs her deep understanding of organizations with a skilled nursing focus. She strives to provide ACHC customers with practical solutions to challenges, while maintaining continuous improvement that raises the bar on patient care.

Posted: October 28, 2025

Surveyors find gaps in compliance. It’s their job to help you see what may have become obscured in day-to-day activity. ACHC’s educational approach makes it easier to welcome those observations and make improvements for better patient care and a high-reliability organization.  

Hospice deficiencies are generally consistent and clustered in Section 5: Provision of Care and Record Management. This year, seven standards were cited on more than 20% of the surveys performed, and all but one came from this section.  

Section 5 standards cover the core provisions of care and services provided by hospices. Multiple disciplines are involved—the care team, attending physician, primary caregiver—and overlooked items are common. Compliance requires rigorous attention to detail and coordination across the interdisciplinary team. Ongoing training and regular audits of documentation can help hospices spot issues early and make adjustments.   

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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