ACHC accreditation: programs, surveys and documentation
Short answer
ACHC accredits home health, hospice, surgery centers, hospitals and more. It says CMS gave it deeming authority for nine programs, so its survey can replace the state's. Deemed surveys are unannounced. Other surveys are scheduled with the provider.
- Deemed survey notice
- Unannounced
- CMS deeming authority (per ACHC)
- Nine programs, including home health, hospice, ASC, hospital and critical access hospital
- Home health
- Deeming authority since 2006
- Hospice
- Deeming authority since 2009
- ASC
- Deeming authority since 2003. Survey typically two days with two surveyors
- After the survey
- Final report within 10 business days. Plan of correction within 30 days
- Accreditation period
- Three years for programs such as office-based surgery and sleep. Confirm for yours
Applies to: Home health agencies and hospices · Ambulatory surgery centers and office-based surgery practices · Acute care and critical access hospitals · Pharmacy, DMEPOS, home infusion, behavioral health and other programs
Who does ACHC accredit?
ACHC says it has CMS deeming authority for nine programs: acute care hospitals, ambulatory surgery centers, clinical laboratories, critical access hospitals, DMEPOS, home health, home infusion therapy, hospice and renal dialysis. Other programs are accreditation only. They include assisted living, behavioral health, dentistry, home care (private duty), office-based surgery, palliative care, pharmacy and sleep. It also offers certifications such as telehealth, stroke and wound care.
How does ACHC relate to CMS deemed status?
| Program | Medicare status |
|---|---|
| Home health | Deeming authority since 2006. A deemed survey results in accreditation and a recommendation for CMS approval. |
| Hospice | Deeming authority since 2009 |
| Ambulatory surgery center | Deeming authority since 2003 |
| Hospital and critical access hospital | Deeming authority for both programs |
| Office-based surgery, behavioral health, sleep | Accreditation only. Not a substitute for Medicare certification. |
ACHC is also on CMS's list of approved accrediting organizations. Accreditation is voluntary. The alternative is a state survey.
How do ACHC surveys work?
| Item | Detail |
|---|---|
| Deemed status surveys | Unannounced. CMS no longer lets accreditors alert organizations beforehand. ACHC used to give community-based programs 30 minutes' notice. |
| Non-deemed surveys | Scheduled with the organization. Office-based surgery, behavioral health and sleep surveys are announced. |
| ASC survey | Typically two days with two surveyors. The ASC must have served at least 10 patients, so a surveyor can review 10 closed records and one open record. |
| Home health | Usually one surveyor. A surveyor in training, a manager or a CMS surveyor overseeing the accreditor may join. |
| Hospice | Record reviews and home visits scale with the number of unduplicated admissions |
| Method | Observation, interviews and document review, with opening and closing conferences. Surveyors do not make the accreditation decision. |
ACHC publishes a three-year accreditation period for programs such as office-based surgery and sleep. Confirm the cycle for your program with your account advisor.
What happens after an ACHC survey?
ACHC's hospice page lists these steps. Ask your account advisor whether the same timeline applies to your program.
- Final survey reportProvided within 10 business days of the last survey day.
- Plan of correctionSubmitted within 30 days of the final report. ACHC accepts or asks for revisions, then sends it to its review committee.
- Decision letterSent within five business days of the review committee's decision.
ACHC recommends submitting a renewal application six months before expiration to avoid a lapse. See the plan of correction guidance.
What quality work does ACHC expect?
ACHC says it presents regulatory requirements as a framework for quality that supports continuous improvement through self-assessment, data analysis and corrective action. Deemed programs must also meet CMS's own QAPI rules:
| ACHC program | CMS QAPI rule | Page |
|---|---|---|
| Home health | 42 CFR 484.65 | Home health QAPI |
| Hospice | 42 CFR 418.58 | Hospice QAPI |
| Ambulatory surgery center | 42 CFR 416.43 | ASC QAPI |
| Hospital | 42 CFR 482.21 | Hospital QAPI |
ACHC's compliance date is the date an organization attests it meets ACHC standards. It does not apply to the Medicare conditions, which apply from the start of patient care.
What documentation should an ACHC-accredited organization keep?
- Self-assessment or mock survey results. ACHC offers a free self-assessment tool.
- The QAPI proof for your CMS rule: adverse event tracking, analyses and project records
- Records available for surveyor sampling, including closed ASC records
- The plan of correction and evidence of each correction
- For first-time community-based applicants, the signed Preliminary Evidence Checklist
- Your renewal application timeline
IncidentKit tracks each plan-of-correction item with an owner, due date and evidence, and keeps the packet current for an unannounced survey.
How IncidentKit supports this requirement
| What the rule asks for | Where it lives in IncidentKit |
|---|---|
| Deemed programs must meet the CMS QAPI rules: 416.43, 418.58, 482.21 and 484.65 | Intake, structured investigations and corrective actions produce the record set each rule asks for. See the matching CMS QAPI page. |
| Adverse event tracking, as each CMS rule defines it | A pack sets incident types, so the hospice's own definition or the home health adverse event categories become structured record types. |
| Plan of correction within 30 days of the final report | Corrective actions with owner, due date, evidence and an effectiveness check, so each correction is provable. |
| Self-assessment, data analysis and corrective action as the quality framework | Analytics cluster incidents by location, shift, equipment and cause, and effectiveness checks close the loop. |
| Readiness for an unannounced deemed survey | Survey packets and the audit trail keep proof current, so there is nothing to assemble on the day. |
Product parts involved: Incident reporting, Investigations and RCA, Corrective actions (CAPA), Analytics, Compliance packets, Audit trail. Capabilities marked “rolling out” are being released in stages; see the changelog.
Frequently asked questions
Are ACHC surveys unannounced?
Deemed status surveys are unannounced, because CMS no longer lets accreditors alert organizations. Other surveys are scheduled. Office-based surgery, behavioral health and sleep surveys are announced.
What happens after an ACHC survey?
A final survey report within 10 business days of the last survey day. A plan of correction within 30 days of the report. A decision letter within five business days of the review committee's decision.
What is the ACHC compliance date?
The date an organization attests it meets ACHC standards. It does not apply to the Medicare Conditions of Participation or state rules, which apply from the start of patient care.
How many patients must a new home health agency or hospice have before survey?
Initial Medicare home health: at least 10 patients needing skilled care, at least seven receiving it at survey time unless the area is rural or medically underserved. Initial hospice: at least five patients, at least three receiving care.
Sources
- ACHC: Frequently asked questions
- ACHC: Accreditation 101
- ACHC: Home health accreditation
- ACHC: Hospice accreditation
- ACHC: Ambulatory surgery center accreditation
- ACHC: Hospital accreditation
- CMS: Accrediting organizations
Reviewed against the sources above on Oct 5, 2026. Rules change: confirm current requirements with the issuing body or your counsel before relying on any summary.
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