Your Compliance Date and Reaccreditation
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 6, 2026
Congratulations! You successfully completed your first Hospice Accreditation survey with ACHC. Now it’s time to ensure the same 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 hospice agency would meet all applicable ACHC Accreditation Standards, which include the Medicare Conditions of Participation (CoPs), beginning on that date and continuing thereafter.
A look back
When you chose your compliance date, there may have been activities completed before that date that did not fully meet ACHC requirements. For example, staff hired prior to your compliance date may not have received orientation to all required topics. They may not have completed annual training required by ACHC or have fully documented competencies.
Your compliance date also applied to patient care activities. Patients admitted prior to the compliance date may not have 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 not cited these 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 compliance/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. During your renewal, any of your hospice's operational processes—emergency preparedness, infection prevention activities, adverse event tracking, and quality assessment and performance improvement (QAPI) initiatives—must demonstrate continuing compliance, including those that required a plan of correction after your initial survey.
Surveyors will expect to see that staff received 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 maintain accreditation but to build a culture of continuous compliance and excellence that exceeds both ACHC Accreditation Standards and the federal and state requirements governing hospice care.
Your accreditation partner
As your partner in accreditation, ACHC offers a variety of resources to help your organization remain survey ready.
The Hospice Accreditation Annual Compliance Checklist is another key resource. It provides 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.)
Congratulations again on your commitment to excellence. Remember that we are here to help. Our customer platform has direct links to many tools and your ACHC Account Advisor is always available to connect you with a clinical expert or to answer process questions that arise. We look forward to our ongoing relationship as you continue to provide exceptional, compassionate care to the patients and families you serve.
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