Achieving and maintaining hospice accreditation is a critical requirement for agencies seeking Medicare certification and long-term operational success. Among the recognized accrediting bodies, Community Health Accreditation Partner (CHAP) plays a major role in evaluating hospice providers for compliance with federal standards.
A CHAP hospice accreditation survey is not just a regulatory checkpoint—it is a comprehensive evaluation of your agency’s clinical operations, documentation systems, interdisciplinary care model, and compliance with Medicare Conditions of Participation (CoPs). For agencies preparing for an initial survey or re-accreditation, understanding exactly what to expect is essential to passing on the first attempt.
This guide provides a detailed overview of the CHAP hospice accreditation survey process, including preparation, survey structure, documentation expectations, common deficiencies, and best practices for success.
Understanding CHAP Accreditation for Hospice
CHAP is a CMS-approved accrediting organization authorized to grant “deemed status,” meaning that agencies accredited by CHAP are considered compliant with Medicare requirements enforced by the Centers for Medicare & Medicaid Services (CMS).
Key Functions of CHAP:
Conduct initial and renewal accreditation surveys
Evaluate compliance with hospice CoPs
Assess clinical quality and operational systems
Provide accreditation decisions
CHAP accreditation is often used as a pathway to Medicare certification for hospice agencies.
Types of CHAP Hospice Surveys
Hospice agencies may undergo different types of surveys depending on their status.
1. Initial Accreditation Survey
Conducted for new hospice agencies
Required before Medicare certification
Focuses heavily on readiness and documentation
2. Renewal Survey
3. Complaint or Validation Survey
CHAP Survey Process: Step-by-Step
Step 1: Application and Readiness
Before the survey, agencies must:
Submit an application to CHAP
Complete required documentation
Demonstrate operational readiness
CHAP will verify that the agency is actively providing services and has sufficient patient volume for review.
Step 2: Survey Scheduling
CHAP schedules the survey, typically within a defined window. Surveys may be announced, but agencies should always maintain readiness for inspection.
Step 3: Onsite Survey Activities
During the survey, CHAP surveyors conduct a comprehensive evaluation.
Step 4: Exit Conference
Surveyors provide:
Preliminary findings
Areas of concern
Next steps
Step 5: Plan of Correction (POC)
If deficiencies are identified, agencies must submit a Plan of Correction outlining corrective actions.
Key Areas Evaluated During a CHAP Hospice Survey
1. Patient Eligibility and Certification
Surveyors review:
Eligibility documentation must be clear, specific, and consistent.
2. Plan of Care (POC)
The POC must:
3. Interdisciplinary Group (IDG) Function
CHAP places strong emphasis on IDG operations.
Surveyors evaluate:
Failure to demonstrate active IDG involvement is a common deficiency.
4. Clinical Documentation
Documentation must support:
Patient eligibility
Skilled care provided
Progress and decline
Surveyors review nursing, social work, spiritual care, and aide notes.
5. Medication Management
Agencies must demonstrate:
6. Quality Assessment and Performance Improvement (QAPI)
CHAP requires a robust QAPI program.
Surveyors evaluate:
7. Infection Control Program
Agencies must implement infection control policies, including:
Staff training
Infection tracking
Prevention protocols
8. Emergency Preparedness
Surveyors review:
Emergency plans
Staff training
Drill documentation
Documentation Requirements for CHAP Surveys
Clinical Records Must Include:
Administrative Documentation:
Personnel Files:
Common CHAP Hospice Survey Deficiencies
1. Weak Physician Narratives
2. Incomplete Plan of Care
3. IDG Documentation Gaps
Missing disciplines
Incomplete meeting notes
4. Lack of Clinical Decline Documentation
5. QAPI Program Deficiencies
6. Inconsistent Documentation
How to Prepare for a CHAP Hospice Survey
1. Conduct a Mock Survey
Simulate a CHAP survey to identify gaps.
2. Audit Clinical Documentation
Review:
3. Strengthen Physician Narratives
Ensure narratives are:
Detailed
Patient-specific
Clinically supported
4. Train Staff
Focus on:
Documentation standards
Survey expectations
Compliance requirements
5. Organize Documentation
Ensure all records are:
Complete
Easily accessible
Well-organized
What Surveyors Look for Beyond Documentation
CHAP surveyors evaluate not just documentation but also:
Staff knowledge and competency
Patient and family satisfaction
Communication among care team members
Compliance culture within the organization
Agencies must demonstrate both compliance and quality care delivery.
After the Survey: What Happens Next
If No Deficiencies:
If Deficiencies Are Found:
Agency submits a Plan of Correction
CHAP reviews corrective actions
Follow-up may be required
Alignment with Medicare Hospice Conditions of Participation
CHAP surveys are designed to ensure compliance with Medicare CoPs, including:
Patient eligibility
Interdisciplinary care
Quality assurance
Documentation standards
Agencies aligned with CoPs are more likely to pass surveys successfully.
Benefits of CHAP Accreditation
CHAP accreditation provides:
Conclusion
A CHAP hospice accreditation survey is a comprehensive evaluation of an agency’s compliance, clinical quality, and operational systems. Preparation is essential, as deficiencies in documentation, IDG processes, or eligibility determination can result in delays or denial of accreditation.
Agencies that invest in mock surveys, staff training, and documentation audits are far more likely to succeed.
Work with HealthBridge for CHAP Survey Preparation
HealthBridge provides specialized consulting and compliance solutions for hospice agencies, including:
CHAP survey readiness assessments
Mock surveys and chart audits
Policy and procedure development
Plan of Correction (POC) support
Ongoing compliance monitoring
HealthBridge helps agencies prepare, pass, and maintain accreditation with confidence.
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