Accreditation is more than a credential in the home health industry. It is a public demonstration of quality, compliance, and operational excellence. For Medicare-certified home health agencies, maintaining accreditation through nationally recognized organizations such as ACHC and CHAP is often essential for deemed status, market credibility, referral relationships, and long-term sustainability.
While achieving accreditation is a significant milestone, maintaining compliance between surveys is where many agencies struggle. Accreditation standards are rigorous, continuously evolving, and closely aligned with federal and state regulatory expectations. Agencies that fail to maintain day-to-day compliance often face condition-level deficiencies, loss of accreditation, corrective action plans, or increased regulatory scrutiny.
This guide provides a comprehensive and practical roadmap for maintaining ACHC and CHAP accreditation compliance, with a focus on systems, leadership accountability, and continuous readiness.
Understanding Accreditation and Deemed Status
Accreditation organizations approved by Centers for Medicare & Medicaid Services grant “deemed status” to home health agencies that meet their standards. Deemed status allows agencies to satisfy Medicare Conditions of Participation requirements without undergoing a separate CMS certification survey, unless triggered by a complaint or validation review.
Two of the most widely recognized accrediting bodies in home health are:
Although both organizations align closely with Medicare regulations, each has unique standards, scoring methodologies, documentation expectations, and survey approaches. Agencies must understand not only the similarities but also the subtle differences between them.
Why Ongoing Accreditation Compliance Matters
Maintaining accreditation compliance is not a one-time event tied to survey dates. Surveyors evaluate whether accreditation standards are embedded into daily operations. Agencies that focus only on “survey prep mode” often experience compliance drift, documentation gaps, and staff inconsistency.
Consistent compliance:
Reduces risk of adverse survey findings
Strengthens patient safety and quality outcomes
Improves staff accountability and performance
Supports payer and referral source confidence
Protects Medicare participation
Accreditation should be treated as an operational framework, not a checklist.
Core Pillars of ACHC and CHAP Compliance
1. Governance and Leadership Oversight
Surveyors expect governing bodies and executive leadership to actively oversee accreditation compliance. This includes:
Regular review of quality and compliance data
Approval of policies and procedures
Oversight of corrective actions
Engagement in strategic planning
A passive governing body is a common accreditation vulnerability. Leadership must be able to articulate how the agency ensures ongoing compliance.
2. Policies and Procedures Alignment
Both ACHC and CHAP require agencies to maintain comprehensive, current, and agency-specific policies. Common deficiencies include:
Policies must align with Medicare Conditions of Participation, accreditation standards, and state regulations. More importantly, staff must be trained to follow them consistently.
3. Clinical Documentation Integrity
Documentation is the most scrutinized element during accreditation surveys. Surveyors review records to validate:
Accurate and timely assessments
Consistency between assessments, plans of care, and visit notes
Skilled need and medical necessity
Physician involvement and orders
Patient progress toward goals
Incomplete, inconsistent, or late documentation remains one of the top drivers of accreditation deficiencies.
4. Quality Assessment and Performance Improvement (QAPI)
ACHC and CHAP place significant emphasis on a functional QAPI program. Agencies must demonstrate:
Use of data to identify trends
Root cause analysis of adverse events
Implementation of improvement actions
Monitoring of outcomes over time
QAPI must be ongoing, interdisciplinary, and documented. A static QAPI binder prepared only for survey does not meet accreditation expectations.
5. Staff Competency and Education
Surveyors assess whether staff are qualified, competent, and adequately trained. Common compliance gaps include:
Missing licensure verification
Incomplete orientation documentation
Lack of competency assessments
Inconsistent annual education
Agencies must maintain organized personnel files and ensure staff can articulate agency policies, patient rights, infection control practices, and emergency procedures.
6. Infection Prevention and Control
Infection control remains a high-risk area during surveys. Agencies must demonstrate:
Active infection prevention programs
Staff education on standard precautions
Surveillance and tracking of infections
Corrective actions for identified risks
Surveyors often interview staff to confirm real-world application, not just written policies.
7. Emergency Preparedness
Emergency preparedness standards require agencies to:
Failure to maintain updated emergency preparedness documentation or training records is a frequent citation.
8. Patient Rights and Satisfaction
Accrediting bodies assess whether agencies respect and promote patient rights, including:
Patient satisfaction data is often reviewed as part of quality oversight.
ACHC vs. CHAP: Key Compliance Considerations
While ACHC and CHAP share regulatory alignment, agencies should be aware of practical differences:
ACHC often emphasizes documentation organization, policy alignment, and operational consistency
CHAP frequently focuses on leadership engagement, performance improvement, and community-based care models
Understanding your accreditor’s survey style helps agencies tailor preparation and ongoing compliance efforts.
Common Reasons Agencies Lose Compliance Between Surveys
Accredited agencies most often fall out of compliance due to:
Staff turnover without adequate onboarding
Policy updates not communicated or implemented
Lack of internal audits
Reactive rather than proactive QAPI programs
Leadership disengagement from compliance activities
Maintaining accreditation requires consistent structure, accountability, and monitoring.
Best Practices for Continuous Accreditation Readiness
High-performing agencies maintain compliance by:
Conducting routine internal audits
Performing mock accreditation surveys
Educating staff continuously
Tracking regulatory updates
Reviewing trends in deficiencies
Accreditation readiness should be embedded into weekly and monthly operations.
Preparing for Reaccreditation Surveys
As reaccreditation approaches, agencies should:
Review prior survey findings
Validate corrective actions remain effective
Conduct comprehensive chart audits
Ensure staff survey readiness
Organize documentation logically
Survey success reflects preparation over years, not weeks.
The Strategic Value of Expert Support
Maintaining ACHC and CHAP accreditation compliance can be resource-intensive, particularly as regulations evolve and operational complexity increases. Many agencies benefit from expert guidance to identify blind spots, strengthen systems, and ensure sustained compliance.
HealthBridge provides comprehensive consulting and management solutions for home health agencies seeking to maintain accreditation excellence. Services include accreditation readiness assessments, mock surveys, QAPI program development, documentation audits, leadership coaching, and ongoing compliance support. HealthBridge partners with agencies to move beyond survey survival toward long-term operational strength.
References:
https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc
https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-484
https://www.cms.gov/medicare/health-safety-standards
https://www.achc.org/accreditation/home-health/
https://www.achc.org/standards/
https://www.chapinc.org/Programs/Home-Health
Disclaimer
HealthBridge is an independent healthcare consulting firm and is not affiliated with, endorsed by, or associated with the Accreditation Commission for Health Care (ACHC), Community Health Accreditation Partner (CHAP), The Joint Commission (JCO), or the Centers for Medicare & Medicaid Services (CMS). All references to regulatory or accreditation standards are provided for general informational purposes only. For the most current, official, and authoritative information, please refer directly to the respective organizations’ official websites and published guidance.
